tag:theconversation.com,2011:/uk/topics/iud-20457/articlesIUD – The Conversation2023-06-01T05:57:19Ztag:theconversation.com,2011:article/2065032023-06-01T05:57:19Z2023-06-01T05:57:19ZWant long-term contraception? There are more effective options than the pill. But they can be hard to find<figure><img src="https://images.theconversation.com/files/529283/original/file-20230531-17-pe8br4.jpg?ixlib=rb-1.1.0&rect=15%2C286%2C3521%2C2068&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-contraceptive-spiral-hands-nurse-device-2206348007">Shutterstock</a></span></figcaption></figure><p>Australians’ access to a range of contraceptive options depends on where they live and how wealthy they are. A recent <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/ReproductiveHealthcare/Report">parliamentary inquiry</a> recommends ways to end this “postcode lottery” for people who want to use long-acting reversible contraception.</p>
<p>There are several types of long-acting reversible contraception: the hormonal contraceptive implant, the hormonal intrauterine devices (IUD) and copper IUDs. </p>
<p>With fewer than <a href="https://www.nejm.org/doi/pdf/10.1056/nejmoa1110855">one in 100 users</a> becoming pregnant in a year while using them (compared to up to <a href="https://theconversation.com/how-effective-is-the-pill-122189">seven</a> in 100 contraceptive pill users) these are the <a href="https://www.nejm.org/doi/pdf/10.1056/nejmoa1110855">most effective</a> contraceptives available. Once they’re inserted into the body, you don’t need to remember to carry a condom, take a daily pill or fill a new script. </p>
<p>So why are they so hard to access in Australia? And what needs to change?</p>
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Read more:
<a href="https://theconversation.com/australian-womens-access-to-abortion-is-a-postcode-lottery-heres-what-needs-to-change-206504">Australian women's access to abortion is a postcode lottery. Here's what needs to change</a>
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<h2>How do they work?</h2>
<p>The <a href="https://www.tandfonline.com/doi/abs/10.1080/13625187.2000.12067162">contraceptive implant</a> (known as Implanon NXT in Australia) is a small flexible rod, inserted just under the skin of the upper inner arm. It releases a progestogen hormone which prevents monthly egg release from the ovary for up to three years. </p>
<p>IUDs are small T-shaped devices which are inserted into the uterus. Hormonal IUDs contain a progestogen hormone and <a href="https://pubmed.ncbi.nlm.nih.gov/21074010/">mainly work</a> by thickening the cervical mucus and preventing sperm from swimming up into the uterus. There are two types of hormonal IUDs: Mirena and Kyleena. Both last up to five years. Kyleena is slightly smaller and contains a lower dose of hormone than Mirena. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/17531610/">Copper IUDs</a> are hormone-free and last up to ten years. They work through their toxic effect on sperm and the egg to prevent fertilisation. </p>
<h2>They have additional benefits for some users</h2>
<p>As well as better protection from pregnancy, some long-acting reversible contraception methods have other benefits. </p>
<p>The hormonal IUD, Mirena, for example, <a href="https://pubmed.ncbi.nlm.nih.gov/35611632/">reduces heavy menstrual bleeding</a>. This can improve people’s quality of life and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC28513/">reduce the need for a hysterectomy</a>.</p>
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<img alt="Clinician talks to patient" src="https://images.theconversation.com/files/529488/original/file-20230601-21858-ivgtnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529488/original/file-20230601-21858-ivgtnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529488/original/file-20230601-21858-ivgtnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529488/original/file-20230601-21858-ivgtnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529488/original/file-20230601-21858-ivgtnh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529488/original/file-20230601-21858-ivgtnh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529488/original/file-20230601-21858-ivgtnh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">IUDs can have other benefits.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/abortion-provider-talking-care-patient-2063751323">Shutterstock</a></span>
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<p>Hormonal pills (containing estrogen) and the vaginal ring can’t be used by people with certain conditions, such as migraine with aura, or by people aged 35 years or older who smoke. This isn’t the case for long-acting reversible contraception methods, which most people can safely use. </p>
<p>Copper IUDs are an <a href="https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016/fsrh-ukmec-full-book-2019.pdf">essential option</a> for people who cannot or prefer not to use hormones. This includes people with hormone-driven cancers such as breast cancer, for whom any hormonal contraceptive would be considered unsafe. </p>
<h2>Why aren’t they more available?</h2>
<p>Access to long-acting reversible contraception is not universal in Australia. </p>
<p>Cost can be a <a href="https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-015-0227-9">considerable barrier</a> to uptake for some people. While the implant and hormonal IUDs are subsidised by the Pharmaceutical Benefits Schedule (PBS), this is not the case for copper IUDs, which can cost up to A$120 for the device. </p>
<p>Out-of-pocket IUD insertion-related costs can also vary from zero to hundreds of dollars if people don’t have access to publicly funded services. </p>
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Read more:
<a href="https://theconversation.com/considering-an-iud-but-worried-about-pain-during-insertion-heres-what-to-expect-179831">Considering an IUD but worried about pain during insertion? Here’s what to expect</a>
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<p>On the supply side, too few health professionals provide these essential services. </p>
<p>Inadequate remuneration for insertion procedures <a href="https://pubmed.ncbi.nlm.nih.gov/35557481/">act as a deterrent</a>. An IUD takes 30 minutes of inserter and assistant time, and the equipment costs around A$25 per insertion. Yet the <a href="http://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=35503&qt=item">Medicare rebate</a> is just A$72.05. Costs may be higher in rural areas, due to higher set-up costs and reduced access to things like sterilising services for procedural equipment.</p>
<p>Insertion and removal of long-acting reversible contraception also requires practical training. This can be costly for GPs and nurses, especially for IUD training, which also means taking around three days off work to achieve the necessary number of supervised IUD insertions. This can be even longer and more costly for rural practitioners, with additional travel time and accommodation costs.</p>
<p>This lack of trained inserters contributes to inequities for people who have chosen a long-acting reversible contraception but can’t find a local practitioner to insert their IUD or implant. </p>
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<img alt="Doctor types on laptop" src="https://images.theconversation.com/files/529487/original/file-20230601-25431-g1chk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529487/original/file-20230601-25431-g1chk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529487/original/file-20230601-25431-g1chk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529487/original/file-20230601-25431-g1chk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529487/original/file-20230601-25431-g1chk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529487/original/file-20230601-25431-g1chk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529487/original/file-20230601-25431-g1chk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Doctors are deterred by inadequate remuneration for IUD and implant insertion.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/NFvdKIhxYlU">Unsplash/National Cancer Institute</a></span>
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<p>Nurses and midwives could <a href="https://pubmed.ncbi.nlm.nih.gov/26662068/">ably fill this gap</a>. There are multiple <a href="https://pubmed.ncbi.nlm.nih.gov/34836756/">successful models</a> of nurse-led long-acting reversible contraception services and postpartum insertion of implants by midwifes nationally and internationally. </p>
<p>However, most nurses aren’t able to access Medicare remuneration, which creates <a href="https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-015-0227-9">additional barriers</a> for this highly skilled workforce to provide these services. </p>
<h2>What are the recommendations for reform?</h2>
<p>The Senate inquiry has recognised these barriers and recommends making contraception universally affordable, and specifically, subsidising copper IUDs. </p>
<p>It also recommends adequate remuneration through Medicare for GPs, nurses and midwives to provide long-acting reversible contraception insertion and removal, and collaborative efforts between the government and medical colleges to improve access to workforce training. </p>
<p>While the recommendations are welcome, they now need to be turned into actions through adequate funding. </p>
<p>The government also needs to fund every Primary Health Network (which plan services) across Australia to identify local gaps and ensure the contraceptive needs of the communities they serve are met equitably, affordably and transparently. </p>
<p>While one size does not fit all, and people must be provided with sufficient and accessible information to make an informed choice, no one who wants an IUD or implant should be denied this choice based on where they live and how much they can pay. </p>
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Read more:
<a href="https://theconversation.com/how-effective-is-the-pill-122189">How effective is the pill?</a>
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<img src="https://counter.theconversation.com/content/206503/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Bateson has received honoraria for attending advisory committees and providing education to health professionals sponsored by Organon and Bayer, and has received untied research support from Organon. </span></em></p><p class="fine-print"><em><span>Kathleen McNamee's employer, Sexual Health Victoria, receives funding from Organon, Mayne Pharma, and Bayer Australia and New Zealand to train and support doctors and nurses in the provision of contraception. She has not received any personal remuneration for these activities.</span></em></p>Fewer than one in 100 people who use IUDs and contraceptive implants become pregnant each year, making them the most effective contraceptives. But they can be difficult to access. Here’s why.Deborah Bateson, Professor of Practice, University of SydneyKathleen McNamee, Adjunct Senior Lecturer, Obstetrics & Gynaecology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1913102023-04-19T12:44:30Z2023-04-19T12:44:30ZEmergency contraception is often confused with abortion pills – here’s how Plan B and other generic versions work to prevent pregnancy<figure><img src="https://images.theconversation.com/files/520092/original/file-20230410-26-r8dpzm.jpg?ixlib=rb-1.1.0&rect=46%2C0%2C5200%2C3440&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Morning-after pills are most effective when taken within three days after sex.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-taking-contraceptive-pill-royalty-free-image/91558808?phrase=Morning%20after%20pill&adppopup=true">Ian Hooton/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Since the overturning of Roe v. Wade in June 2022 and the <a href="https://theconversation.com/supreme-court-overturns-roe-upends-50-years-of-abortion-rights-5-essential-reads-on-what-happens-next-184697">end of constitutional protection for abortion</a>, emergency contraception has become more difficult to obtain and – more than ever – shrouded in misinformation. </p>
<p>Attempting to control inventory, Amazon, Rite Aid and Walmart have <a href="https://www.theguardian.com/society/2022/jun/28/emergency-contraception-pills-pharmacies">imposed purchase limits on the emergency contraception known as Plan B</a> since the Supreme Court’s ruling. Panicked buyers have been trying to stock up on the drug in case it becomes unavailable. </p>
<p>Several legislators and proposed bills have <a href="https://nwlc.org/resource/dont-be-fooled-birth-control-is-already-at-risk/">conflated emergency contraception with abortion</a> and are trying to limit access to it. The <a href="https://theconversation.com/anti-mifepristone-court-decisions-rely-on-medical-misinformation-about-abortion-and-questionable-legal-reasoning-203742">recent court ruling</a> <a href="https://www.washingtonpost.com/politics/2023/04/07/texas-abortion-pill-ruling-mifepristone/">blocking access to mifepristone</a> – which has been approved by the FDA since 2000 – is an ominous sign to many that emergency contraception could be the next target. </p>
<p>Regardless of one’s stance on abortion, it is important to understand why emergency contraception should be a basic component of women’s reproductive health care and family planning services. As a researcher of <a href="https://www.researchgate.net/profile/Amie-Ashcraft">women’s sexual and reproductive health and decision-making</a>, I have extensively researched access to emergency contraception.</p>
<h2>What is emergency contraception?</h2>
<p>Emergency contraception is the only way to prevent pregnancy after sex has already occurred. It can be used when no contraception was used or it was used incorrectly, such as with missed birth control pills or broken condoms. Emergency contraception is also used to prevent pregnancy after sexual assault or rape. </p>
<p>Emergency contraception can take the form of pills – sometimes called the morning-after pill – or <a href="https://www.acog.org/womens-health/faqs/long-acting-reversible-contraception-iud-and-implant">an intrauterine device, or IUD</a> that delays ovulation. </p>
<p>There are two types of emergency contraception pills. The most widely known is <a href="https://medlineplus.gov/druginfo/meds/a610021.html">levonorgestrel</a>, which is sold in the U.S. under the brand name <a href="https://www.planbonestep.com/">Plan B</a>, along with numerous generic versions. </p>
<p>Levonorgestrel was <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/plan-b-one-step-15-mg-levonorgestrel-information#:%7E">first approved for over-the-counter sale</a> to women 18 and older in 2006, and in 2013 age restrictions were removed. </p>
<p>The second type of emergency contraception pill is ulipristal acetate, which is sold under the brand name ella. Both Plan B and ella work by delaying ovulation. In addition, ella <a href="https://doi.org/10.3109/09513590.2014.950648">also thins the uterus lining</a> so that even if an egg were fertilized, it is harder for it to implant in the uterus to start a pregnancy. </p>
<p>Both types of pills are effective at preventing pregnancy. Plan B is most effective if taken within three days of sex, with some declining effectiveness on days four and five. Ella is effective if taken within five days of sex and, unlike Plan B, is equally effective all five days.</p>
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<figcaption><span class="caption">Studies show emergency contraception prevents pregnancy only before the egg is fertilized, not after.</span></figcaption>
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<p>The most effective types of emergency contraception are IUDs that are inserted by a health care provider. Copper IUDs – also referred to as nonhormonal IUDs – are sold under the brand name Paragard. They release into the uterus copper ions that are <a href="https://www.mayoclinic.org/tests-procedures/paragard/about/pac-20391270">toxic to both eggs and sperm</a>. This allows them to be used as emergency contraception if inserted within five days after sex, and as ongoing contraception for up to 10 years. </p>
<p>Levonorgestrel IUDs – referred to as hormonal IUDs – are sold under the brand names Mirena, Liletta, Kyleena and Skyla. The levonorgestrel released into the uterus makes the mucus around the cervix thicker so that a sperm cannot penetrate to fertilize the egg, and it is as effective as the copper IUD when inserted as emergency contraception <a href="https://doi.org/10.1056/NEJMoa2022141">for up to five days after sex</a>. Both Paragard and Mirena IUDs have been approved by the FDA for use as contraception, but they are <a href="https://www.contemporaryobgyn.net/view/updates-on-emergency-contraception">not yet approved specifically for use as emergency contraception</a>.</p>
<h2>How is emergency contraception different from the abortion pill?</h2>
<p>For many years, the way that emergency contraception works has been misunderstood. There has been confusion about whether emergency contraception is an abortifacient – that is, a medication that triggers an abortion. The key difference is that the abortion pill works only when a woman is pregnant, and emergency contraception works only when she is not.</p>
<p>The so-called abortion pill is used for a medication abortion and actually consists of <a href="https://www.bedsider.org/abortion/abortion-pill">two separate pills that do different things</a>. </p>
<p>The <a href="https://theconversation.com/what-the-fdas-rule-changes-allowing-the-abortion-pill-mifepristone-to-be-dispensed-by-pharmacies-mean-in-practice-5-questions-answered-197339">first of these pills is mifepristone</a>, which functions to block production of the pregnancy hormone progesterone so that the uterus lining thins and the embryo detaches from it. This is the pill that is receiving national attention because of clashing court rulings over access, a battle that is headed to <a href="https://www.statnews.com/2023/04/13/abortion-mifepristone-texas-appeals-court-restores-access-access/">the Supreme Court</a>.</p>
<p>The second pill, misoprostol, stimulates contractions in the uterus to eject the embryo and gestational sac. Emergency contraception prevents a pregnancy before it occurs, whereas the abortion pill ends a pregnancy once it’s begun.</p>
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<figcaption><span class="caption">Some observers say there’s a possibility of an eventual ban on Plan B and other contraceptives.</span></figcaption>
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<h2>How do abortion restrictions jeopardize emergency contraception?</h2>
<p>With the increase in abortion restrictions, access to a full range of contraceptive options – including emergency contraception – is more critical than ever. </p>
<p>There are already numerous barriers to obtaining emergency contraception in a timely manner. The most effective types of emergency contraception, ulipristal acetate and both hormonal and nonhormonal IUDs, must be obtained from a health care provider. This means a woman needs an appointment – usually available only on a weekday during business hours – as well as transportation and the means to pay for the appointment, either through health insurance or self-pay. She may need to take time off of work to attend the appointment, or she may need to obtain child care.</p>
<p>For many women in poor, rural or geographically isolated neighborhoods, these barriers are difficult to surmount. This is particularly true given the short window of time in which emergency contraception is effective.</p>
<p>Levonorgestrel emergency contraception pills are available over the counter and should be easily accessible, but individuals trying to purchase them run into numerous obstacles. These include <a href="https://doi.org/10.1016/j.japh.2020.07.027">low stocks in pharmacies</a> – especially independent pharmacies – and <a href="https://doi.org/10.1016/j.srhc.2022.100765">point-of-sale restrictions</a>, such as requirements that purchasers be a certain age, show identification or have parental consent. People also encounter high rates of misinformation about when to take levonorgestrel for maximum effectiveness and about sales restrictions. Finally, they encounter pharmacy staff who object to selling it because they <a href="https://doi.org/10.1177/0969733020918926">misunderstand how it works</a>.</p>
<p>The surge in demand for emergency contraception since the reversal of Roe v. Wade and the <a href="https://www.theguardian.com/society/2022/jun/28/emergency-contraception-pills-pharmacies">purchase limits put on it by retailers</a> have exacerbated these access challenges. </p>
<h2>What are the benefits of emergency contraception?</h2>
<p>Access to emergency contraception promotes women’s health in several ways. <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">Nearly half of pregnancies in the U.S. are unintended</a>, and emergency contraception can prevent about <a href="https://www.who.int/news-room/fact-sheets/detail/emergency-contraception">95% of unwanted or mistimed pregnancies</a> when used within five days of sex. It can also be used as a backup option when another form of contraception fails. And it can be given to survivors of sexual assault. Emergency contraception also <a href="https://www.guttmacher.org/news-release/2005/emergency-contraception-ec-played-key-role-abortion-rate-declines">reduces the need for abortions</a>.</p>
<p>Overall, access to a full range of contraceptive options – including emergency contraception – gives women greater control over their reproductive choices. The ability to control the number and spacing of their pregnancies improves the health, social and <a href="https://iwpr.org/iwpr-issues/reproductive-health/the-economic-effects-of-contraceptive-access-a-review-of-the-evidence/">economic outcomes</a> of both women and their families.</p><img src="https://counter.theconversation.com/content/191310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amie Ashcraft does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The increase in abortion restrictions may also lead to a decline in access to emergency contraceptives.Amie Ashcraft, Service Assistant Professor in Family Medicine, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1947962022-12-09T13:29:08Z2022-12-09T13:29:08ZWhat is voluntary sterilization? A health communication expert unpacks how a legacy of forced sterilization shapes doctor-patient conversations today<figure><img src="https://images.theconversation.com/files/499824/original/file-20221208-9366-xogfk5.jpg?ixlib=rb-1.1.0&rect=55%2C64%2C6132%2C3877&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Conversations between patients and their doctors about permanent birth control procedures can at times be fraught and influenced by long-standing stigmas.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-woman-is-patient-in-hospital-clinic-royalty-free-image/1432735081?phrase=birth%20control&adppopup=true">Courtney Hale/E+ via Getty Images</a></span></figcaption></figure><p><a href="https://www.acog.org/womens-health/faqs/sterilization-for-women-and-men">Sterilization</a> is a <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/benefits-and-risks-of-sterilization">safe and effective</a> form of permanent birth control <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/benefits-and-risks-of-sterilization">used by more than 220 million couples</a> around the world. Despite its prevalence, however, patients seeking sterilization from their doctors often face a surprising number of challenges.</p>
<p>In men, the sterilization process is known as a <a href="https://www.mayoclinic.org/tests-procedures/vasectomy/about/pac-20384580">vasectomy</a>, which involves severing the tubes that carry the supply of sperm to the semen. In women, sterilization involves a procedure called <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/sterilization-of-women-ethical-issues-and-considerations">tubal ligation</a>. In this form of permanent birth control, the fallopian tubes are severed – or ligated – preventing eggs produced by the ovaries from traveling through the fallopian tubes to fertilize an egg. <a href="https://doi.org/10.4103/1008-682X.175091">Vasectomies</a> and <a href="https://doi.org/10.3389/fsurg.2018.00079">tubal ligations</a> can be reversed in some cases, although success rates vary widely.</p>
<p>A 2018 study found that female sterilization is the <a href="https://www.guttmacher.org/fact-sheet/contraceptive-method-use-united-states">No. 1 form of contraception in the U.S.</a>, used by nearly 1 in 5 women ages 15 to 49. And a partner’s vasectomy is the fifth leading contraceptive, relied on by 5.6% of women in that age group, after birth control pills, male condoms and intrauterine devices, or IUDs. </p>
<p>I’m <a href="https://comm.uconn.edu/person/elizabeth-hintz/">a scholar of health communication</a> with expertise in women’s health issues and <a href="https://scholar.google.com/citations?user=ByZ6qXEAAAAJ&hl=en&inst=9808383360503840251">interactions between patients and doctors</a>. My work explores how patients manage the stigma associated with seeking sterilization and communicate with others about their reproductive decisions. My research also illuminates why patients find talking about sterilization with their doctors so challenging. </p>
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<a href="https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustrated anatomical examples of vasectomy on the left and tubal ligation on the right." src="https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=296&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=296&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=296&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=372&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=372&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499870/original/file-20221208-19434-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=372&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The two common forms of sterilization, or permanent birth control, are vasectomy for men and tubal ligation for women.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/male-and-female-sterilization-royalty-free-illustration/1133181391?phrase=vasectomy%20tubal%20ligation&adppopup=true">elenabs/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>Access to sterilization</h2>
<p><a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/sterilization-of-women-ethical-issues-and-considerations">Ethical guidelines</a> from the American College of Obstetricians and Gynecologists recommend that doctors should respect a female patient’s wishes as a matter of “reproductive justice” when deciding whether to approve their request for voluntary sterilization. The <a href="https://www.auanet.org/guidelines-and-quality/guidelines/vasectomy-guideline">American Urological Association</a>, on the other hand, does not appear to offer ethical guidelines concerning the provision of vasectomy services for male patients.</p>
<p>Yet research has documented that patients seeking sterilization procedures, especially women, are sometimes told that their <a href="https://doi.org/10.1002/hast.216">doctors will not perform the procedure</a> because of the person’s age, number of children or potential risk of regret, among other factors. Providers may also refuse to perform sterilization procedures for other reasons, including <a href="https://scholarship.law.umn.edu/lawineq/vol32/iss1/5/">fear of legal culpability</a>, backlash from the medical community or <a href="https://doi.org/10.1016/j.jogc.2017.05.034">conscientious refusal</a>. The latter means that a doctor cannot be compelled to provide a medical service that goes against their best judgment or personal convictions. </p>
<p>This hesitancy to approve sterilization requests reflects the tension over forced sterilization in the past.</p>
<h2>How history has shaped views on sterilization</h2>
<p>Perceptions of sterilization in the U.S. have been marred by a <a href="https://www.genome.gov/about-genomics/fact-sheets/Eugenics-and-Scientific-Racism">dark history of eugenics</a>, in which racist ideas about who ought to have children have shaped reproductive policies and doctors’ reproductive counseling. And these views have given rise to the term “voluntary” sterilization, meant to contrast with the “involuntary” – or forced – sterilization of earlier decades.</p>
<p>From the late 1800s until the late 1940s, eugenicist movements sought to preserve racial purity by limiting the breeding of people who were considered “unfit” and promoting the proliferation of those who were white and of European descent, from middle or upper classes and <a href="https://doi.org/10.1016/0277-9536(91)90327-9">considered able-bodied and of sound mind</a>. Widespread federally funded involuntary sterilizations <a href="https://www.ecfr.gov/current/title-42/chapter-I/subchapter-D/part-50/subpart-B/section-50.205">continued in the U.S. until 1979</a>.</p>
<p>In contrast, women who were poor, disabled, immigrant, Black, Hispanic or Indigenous who sought to have children often <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/sterilization-of-women-ethical-issues-and-considerations">faced coercive or forced sterilization</a>, sometimes <a href="http://www.jstor.org/stable/40891307">without their consent or knowledge</a>.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/6zCpRVP1DgQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Women of color were frequent targets of forced sterilization campaigns during the eugenics movement of the early 1900s in the U.S.</span></figcaption>
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<p>When women who were considered “desirable” sought to limit their family size or forgo having children altogether through voluntary sterilization, they were <a href="https://doi.org/10.1016/0277-9536(83)90161-2">sometimes denied the procedure</a>. That trend <a href="https://doi.org/10.5744/rhm.2022.50014">continues today</a> despite ethical guidelines recommending otherwise, since doctors cannot be compelled to perform medical procedures they find objectionable. Furthermore, sterilization services, like other reproductive health services, are often <a href="https://theconversation.com/a-growing-number-of-women-give-birth-at-catholic-hospitals-where-they-do-not-receive-the-same-reproductive-health-options-including-birth-control-provided-at-other-hospitals-184813">not offered at religiously affiliated hospitals</a>.</p>
<h2>Disparities in sterilization access</h2>
<p>These cultural views contribute to disparities in access to sterilization that persist today.</p>
<p>In 1979, <a href="https://opa.hhs.gov/sites/default/files/2020-07/consent-for-sterilization-english-updated.pdf">federal legislation</a> went into effect to halt Medicaid-funded involuntary sterilizations and to limit Medicaid-funded sterilization services to any person of sound mind over the age of 21. But ironically, this legislation – which was designed to prohibit involuntary sterilization – now restricts some patients who are <a href="https://doi.org/10.1002/hast.216">seeking sterilization</a>.</p>
<p>Laws vary widely from state to state, meaning that <a href="https://scholarship.law.umn.edu/lawineq/vol32/iss1/5/">where you live</a> dictates how accessible voluntary sterilization is to you. For example, in Kansas, the most <a href="https://scholarship.law.umn.edu/lawineq/vol32/iss1/5/">legally restrictive</a> U.S. state, individual doctors are not held accountable for refusing to perform sterilizations, even if they are medically necessary. In addition, medical facilities and individual doctors can also legally refuse to provide information or refer patients elsewhere to procure the procedure. </p>
<p>In contrast, in California – a state that has progressive reproductive health care rights – a right to voluntary sterilization is <a href="https://california.public.law/codes/ca_health_and_safety_code_section_1258">enshrined in law</a>. This means that patients cannot be discriminated against because of factors like age or the number of children they have. Yet forced sterilization is <a href="https://law.justia.com/codes/california/2017/code-prob/division-4/part-3/chapter-6/section-1952/">still legal</a> in California for patients with developmental disabilities who are under conservatorship. </p>
<p>This patchwork of policies across U.S. states creates room for bias in the patient counseling process. Today, when Black and Native American women seek sterilization voluntarily, they are still <a href="https://doi.org/10.1177/1557988309337619">more than twice as likely as non-Hispanic white women</a> to be approved for the procedure by their doctors. In my view, this shows that decisions about who can be sterilized are still inherently attached to <a href="https://doi.org/10.5744/rhm.2022.50014">racial bias as well as gender and class bias</a>.</p>
<h2>The implications of the fall of Roe</h2>
<p>In the aftermath of the <a href="https://www.brennancenter.org/our-work/research-reports/roe-v-wade-and-supreme-court-abortion-cases#">fall of Roe v. Wade</a>, which overturned nearly 50 years of abortion rights, people living in at least 13 U.S. states may now be in a double bind: unable to find a doctor who <a href="https://doi.org/10.5744/rhm.2022.50014">will grant them the permanent sterilization they desire</a> to prevent an unwanted pregnancy, and also unable to access an abortion should a pregnancy occur.</p>
<p>With abortion access reduced in many states after the Supreme Court’s ruling overturning Roe v. Wade, it’s more important than ever for patients to be able to discuss voluntary sterilization freely with their medical providers.</p><img src="https://counter.theconversation.com/content/194796/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Hintz does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The term voluntary sterilization, referring to the choice to receive permanent birth control, arose as a contrast to the involuntary, or forced, sterilization that stems from the eugenics movement.Elizabeth Hintz, Assistant Professor of Health Communication, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1641952021-07-14T15:03:20Z2021-07-14T15:03:20ZBirth control continues to fail women – so why has nothing changed?<figure><img src="https://images.theconversation.com/files/411195/original/file-20210714-25-1s4vtc6.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5607%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Unpleasant side effects from contraceptives are experienced by many women.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/gynecology-consultation-181677890">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>The hunt for a “<a href="https://sitn.hms.harvard.edu/flash/2021/a-potential-male-oral-birth-control-pill-may-be-on-the-horizon/">male birth control pill</a>” is a topic that often grabs attention. But so far no products have been licensed for use, either because they haven’t been effective enough, or because of <a href="https://www.newscientist.com/article/2110729-male-contraceptive-injection-works-but-side-effects-halt-trial/">negative side effects</a> – including depression, mood disorders and acne – that halted trials.</p>
<p>Current contraceptive options for men are <a href="https://pubmed.ncbi.nlm.nih.gov/10785217/">limited</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254803/">not always effective</a> – so it’s no wonder research continues in this area. But, while this is important, it’s critical that this isn’t at the expense of improving contraceptives currently available for women.</p>
<p>Since the female birth control pill first <a href="https://www.theguardian.com/society/2007/sep/12/health.medicineandhealth">became available</a> in the 1960s, it has allowed many to control their own fertility and manage conditions such as dysmenorrhoea (painful periods), non-menstrual pelvic pain and heavy menstrual bleeding. </p>
<p>But despite these benefits, birth control options are still failing women. This is largely because of the <a href="https://www.bbc.com/future/article/20180823-women-speak-about-side-effects-of-the-birth-control-pill">unpleasant side effects</a> many people experience when using them – which in some cases severely <a href="https://www.fertstert.org/article/S0015-0282(17)30247-9/fulltext">decreases quality of life</a>.</p>
<p>Women often have to put up with side effects when using contraceptives, such as irregular bleeding, bloating and headaches. In some cases, these side effects are more serious, and may include high blood pressure, <a href="https://www.bmj.com/content/373/bmj.n1159/rr-4">blood clots</a> and stroke. Research has also found a link between the pill and increased <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796">risk of depression</a>, as well as <a href="https://pubmed.ncbi.nlm.nih.gov/16913282/">decreased sexual desire and libido</a>. </p>
<p><a href="https://apps.who.int/iris/handle/10665/75429">Side effects</a> are the reason around one-third of women stop their contraception in the first year of use. Perhaps as a result, use of the contraceptive pill in the UK <a href="https://digital.nhs.uk/data-and-information/publications/statistical/sexual-and-reproductive-health-services/2018-19">decreased from 45% in 2015 to 39% in 2019</a>.</p>
<p>It isn’t just the pill that needs improvement. Long-acting reversible contraceptives – such as inter-uterine devices (IUDs) and contraceptive implants – are used by around <a href="https://pubmed.ncbi.nlm.nih.gov/29972356/">12% of women</a> in the UK, but also come with their own side effects and disadvantages. </p>
<p>Like the pill, hormonal IUDs (a small device that is placed in the uterus, where it releases hormones) can <a href="https://pubmed.ncbi.nlm.nih.gov/24695563/">cause side effects</a> such as irregular or missing periods, headaches, nausea, hair loss, depression, and decreased libido. Even <a href="https://pubmed.ncbi.nlm.nih.gov/19341847/">non-hormonal IUDs</a> (such as the copper IUD) can cause heavier periods, longer menstrual cycles and increased pain – causing many women to have them removed early. Many women also report experiencing <a href="https://www.bbc.co.uk/news/health-57551641">painful IUD fittings</a> – often <a href="https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/method-specific/intrauterine-contaception/">without the use</a> of local anaesthetic gels. </p>
<figure class="align-center ">
<img alt="An intrauterine device." src="https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Both hormonal and non-hormonal IUDs can cause side effects.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/iud-174193595">Image Point Fr/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Finding a contraceptive method that works usually involves a lot of <a href="https://sexualhealthdorset.org/contraception">trial and error</a>. This is partly because clinicians don’t have access to large-scale and detailed data which could help them predict which method will work best for different people. The presence of side effects and their severity differs between women, depending on their sensitivity to hormonal changes – and <a href="https://www.sciencedaily.com/releases/2020/05/200512134532.htm">potentially because of genetics</a>.</p>
<h2>Need for improvement</h2>
<p>There’s a clear need for large-scale clinical trials into new and existing forms of birth control. Yet despite this, little investment is actually put into making this happen, and priority tends to be given to other areas of research. For example, between 2017 and 2020, there were only 23 <a href="https://clinicaltrials.gov/ct2/results?cond=contraception&strd_s=01%2F01%2F2017&strd_e=07%2F12%2F2020&recrs=b&recrs=a&recrs=f&recrs=d&recrs=g&recrs=h&recrs=e&recrs=i&age_v=&age=1&gndr=Female&type=&rslt=&phase=4&phase=0&phase=1&phase=2&phase=3&fund=2&Search=Apply">industry-funded clinical trials</a> into contraceptives, compared to <a href="https://pharmaintelligence.informa.com/resources/product-content/clinical-trials-2019-roundup">600 for cardiovascular drugs and 140 for treatment relating to eye disorders</a>. </p>
<p>Most shockingly, only 2% of the revenue made by pharmaceutical companies selling contraception goes back into <a href="https://www.bloomberg.com/news/articles/2019-08-08/better-birth-control-exists-but-big-pharma-isn-t-interested">research and development</a>. Even when methods are improved or refined, they’re often <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3136-4">not available worldwide</a> due to local regulations and health systems. </p>
<p>Access to preferred contraception in the UK (such as specific brands) is also largely dependent on commissioning systems (which assesses needs, and plan purchasing and monitoring of health services in the NHS) and contraceptive budgets – which were <a href="https://www.theguardian.com/society/2020/sep/10/women-in-uk-struggling-to-access-contraception-as-result-of-underfunding">cut by 13%</a> between 2015 and 2018. </p>
<p>Such budget cuts may mean a person has to switch from a brand they’re happy with to one that doesn’t work as well for them. And though the UK has now allowed <a href="https://www.gov.uk/government/news/first-progesterone-only-contraceptive-pills-to-be-available-to-purchase-from-pharmacies">progesterone-only pills</a> to be bought over the counter without a prescription, women still have limited ways to access birth control – and the costs associated with it may be too much for some.</p>
<p>Alongside these issues of access is a continued lack of research and development into women’s contraceptives for a variety of different reasons. For one, there’s little incentive to improve them, as it has already been proved that they prevent pregnancy. In addition, funding bodies are often interested in areas of research that affect all people – not just women – so funding will be prioritised to them. Many women will also continue using birth control despite side effects because they don’t want to get pregnant – so many developers may not see improving formulations as necessary. </p>
<p>Although there’s a clear need to develop better male contraceptives, much still needs to be done to address the inequalities women currently experience when it comes to sexual and reproductive health. The <a href="https://www.gov.uk/government/consultations/womens-health-strategy-call-for-evidence/womens-health-strategy-call-for-evidence">Women’s Health Strategy</a> has recently sought to collect views on women’s health to ensure that women’s voices are at the centre of new health agendas – which will hopefully help inform policies, strategies and healthcare. There are also numerous trials ongoing seeking to <a href="https://www.nature.com/articles/d41586-020-03532-6">improve contraceptive options</a> for women.</p>
<p>But it isn’t solely up to pharmaceutical companies to bring about changes – it will be up to regulators to listen to women when assessing the effectiveness of new contraceptive methods, and clinicians, to listen to patients’ concerns and questions.</p><img src="https://counter.theconversation.com/content/164195/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bethan Swift receives funding from Mustafa Bahceci (Bahceci Health Group, Istanbul, Turkey) for her Doctor of Philosophy at the University of Oxford (2019-2022).</span></em></p><p class="fine-print"><em><span>Christian Becker currently receives research funding from the European Comission and Bayer Healthcare. Both are not related to this article.</span></em></p>Despite side effects, women continue to take contraceptives because there are no better options available.Bethan Swift, PhD candidate in Women's and Reproductive Health, University of OxfordChristian Becker, Associate Professor, Nuffield Department of Obstetrics and Gynaecology,, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1377592020-05-20T12:12:34Z2020-05-20T12:12:34ZSex talk: Common misunderstandings doctors confront about preventing pregnancy<figure><img src="https://images.theconversation.com/files/332858/original/file-20200505-83730-1ckwnv3.jpg?ixlib=rb-1.1.0&rect=41%2C0%2C5556%2C3740&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Condoms can act as a disease barrier. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/women-with-condom-royalty-free-image/86479934?adppopup=true&uiloc=thumbnail_similar_images_adp">ThinkStockImages/Stockbyte Collection via GettyImages</a></span></figcaption></figure><p>Sex is one of the most natural things in the world – none of us would be here without it. Yet there are many things about sex that need to be learned. Even today, 60 years after the introduction of <a href="https://www.npr.org/2020/05/09/852807455/how-the-approval-of-the-birth-control-pill-60-years-ago-helped-change-lives">oral contraceptives</a>, almost half of pregnancies worldwide are <a href="https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/index.htm">unintended</a>. Avoiding pregnancy takes planning, and health professionals can do a lot to help patients better understand contraception. </p>
<p>As an <a href="https://medicine.iu.edu/faculty/6855/gunderman-richard">academic physician</a>, I teach an annual course at the Indiana University School of Medicine called “Sexuality for the Clinician,” an important topic often not <a href="https://www.sexhealthmatters.org/resources/summit-on-medical-school-education-in-sexual-health">well covered</a> in medical schools. In my classes, medical students report misunderstandings they encounter among patients about various topics, including contraception. </p>
<p>Some of these wrong ideas are mentioned year after year, and correcting them presents a prime opportunity to enhance sexual health. Here are four common ideas about contraception that are incorrect, each representing a real patient’s story.</p>
<h2>Rhythm method</h2>
<p>The pregnancy test of a patient in her 20s came back positive. She protested to her physician that she couldn’t be pregnant. Her physician asked what form of contraception she and her husband had been using. She responded that they scrupulously avoided sex during her “fertile time.” Upon further questioning, the patient revealed her understanding that pregnancy could only occur on a single day each month.</p>
<p>In reality, assuming a woman has a 28-day menstrual cycle, there are about <a href="https://www.ncbi.nlm.nih.gov/pubmed/7477165">six days</a> during each cycle when sex can result in pregnancy. While a woman’s egg retains its fertility for up to 24 hours after ovulation, the release of an egg from the ovary, sperm can remain viable in the female reproductive tract for up to five days.</p>
<p>This means that patients employing the so-called “rhythm method,” one of the least <a href="https://www.mayoclinic.org/tests-procedures/rhythm-method/about/pac-20390918">reliable</a> forms of contraception, need to avoid sex for at least six days in the middle of each cycle.</p>
<h2>The pill</h2>
<p>A teenager using oral contraceptives became pregnant. When her physician asked how she had been taking her pills, she said that whenever she missed a pill, she would double up the next day. Once she missed taking her pills for five consecutive days. So, on the sixth day she took six pills. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=442&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=442&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=442&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=556&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=556&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334546/original/file-20200513-82379-brjftm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=556&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The pill was introduced in 1960.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/The-Pill-Turns-50/6cfc9837dff244dc88d906430d331ce2/90/0">AP Photo/Jerry Mosey</a></span>
</figcaption>
</figure>
<p>One way to help patients use medication properly is to explain how it works, including why they need to take it regularly. In this case, providing the patient with a basic explanation of how <a href="https://academic.oup.com/humrep/article/22/12/3078/2384734">oral contraceptives work</a> could be beneficial. </p>
<p>While there are different types of “the pill,” most contraceptives work by preventing ovulation. The brain’s pituitary gland, the so-called “<a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/the-pituitary-gland">master gland</a>” of the hormonal system, detects stable high levels of the pill’s ovarian hormones in the blood. As a result, the hormone that stimulates ovulation isn’t released. But a pill must be taken every day to keep levels sufficiently high to prevent an egg from being released.</p>
<h2>Breastfeeding</h2>
<p>A new mother with a four-month-old baby expressed her fear to her doctor that she was pregnant again. How could this be, she asked, since she had been breastfeeding her baby since birth? The patient was correct that breastfeeding can suppress ovulation, but only if breastfeeding is frequent enough.</p>
<p>As it turned out, while the patient had been breastfeeding her baby since birth, she had also been feeding the baby formula, limiting breastfeeding to two or three times each day. In addition, her menstrual cycle had resumed the previous month. </p>
<p>Breastfeeding can be effective as a means of <a href="https://www.llli.org/breastfeeding-info/fertility/">contraception</a> in the first six months after birth. The hormones produced by the mother’s body during breastfeeding naturally suppress the pituitary gland’s secretion of hormones necessary to ovulate. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334543/original/file-20200513-82375-1sygbf1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334543/original/file-20200513-82375-1sygbf1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=351&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334543/original/file-20200513-82375-1sygbf1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=351&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334543/original/file-20200513-82375-1sygbf1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=351&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334543/original/file-20200513-82375-1sygbf1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=441&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334543/original/file-20200513-82375-1sygbf1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=441&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334543/original/file-20200513-82375-1sygbf1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=441&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">World Breastfeeding Week.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Romania-Breastfeeding/7119b75d27bd4ca8baf9480e5bfae2dd/68/0">AP Photo/Andreea Alexandru</a></span>
</figcaption>
</figure>
<p>However, the baby must be exclusively breastfed and feed at least every four hours during the day and every six hours at night. Otherwise, breastfeeding will not adequately suppress pituitary secretion, and pregnancy can occur. </p>
<h2>Sexually transmitted disease</h2>
<p>A teenager came to a sexual health clinic complaining of symptoms of itching, rash and painful urination, which her physician suspected was the result of a sexually transmitted infection. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334541/original/file-20200513-82379-tq0pon.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The basic equipment for safe sex.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/conceptual-importance-of-using-condoms-royalty-free-image/1149026078?adppopup=true">lucapierro/via Getty Images</a></span>
</figcaption>
</figure>
<p>When her doctor asked her about contraception, she reported that she was “on the pill.” Therefore, she said, she could not have an STI. </p>
<p>Many patients mistakenly assume that, in addition to preventing pregnancy, contraceptives can prevent STIs. While oral and other types of contraceptives, such as IUDs and hormonal implants, are usually highly effective in preventing pregnancy, they do nothing to reduce the risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/11518896">STIs</a>. </p>
<p>The only widely used form of contraception that reliably prevents STIs is the condom. It creates a barrier between the skin and bodily fluids of sex partners. To prevent infection, condoms need to be used in addition to other forms of contraception.</p>
<h2>Sex and medicine</h2>
<p>These are a few examples of common <a href="https://www.ncbi.nlm.nih.gov/pubmed/11255825">misunderstandings</a> that patients may harbor about contraception. Others include the idea that pregnancy can occur only if the woman has an orgasm, if sex occurs in certain positions or if the woman refrains from various cleansing practices, such as douching or taking a shower. In fact, none of these situations is likely to alter the probability of pregnancy in a reliable way. </p>
<p>Misunderstandings about sex include not only contraception but topics such as sexual response, sexual dysfunction and sexually transmitted infections. Such misconceptions serve as stark reminders that many people have not been well educated about essential aspects of sexual health. Families, schools and health professionals have a lot of work to do. </p>
<p>[<em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>.]</p><img src="https://counter.theconversation.com/content/137759/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Gunderman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Doctors hear many of the same basic questions about sex from their patients.Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/921162018-05-22T19:37:55Z2018-05-22T19:37:55ZDon’t want to take a contraceptive pill every day? These are the long-acting alternatives<figure><img src="https://images.theconversation.com/files/216981/original/file-20180501-135830-c6f77r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">At last count, 11% of Australian women used long-acting reversible contraception methods.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/fKddmPKvv9U">Ravi Roshan/Unsplash</a></span></figcaption></figure><p><em>ON THE PILL: In this <a href="https://theconversation.com/au/topics/pill-series-52834">seven-part series</a> we explore the history, myths, side-effects and alternatives of the pill, and why it’s the most popular form of contraception in Australia.</em></p>
<hr>
<p>The arrival of the pill in 1961 was pivotal in enabling women to control their fertility with a method unrelated to sex. <a href="https://theconversation.com/reporting-a-few-cases-of-negative-side-effects-from-long-acting-contraceptives-is-alarmist-and-damaging-89074">Long-acting reversible contraception</a> (LARC) methods add another dimension to contraceptive choice, freeing women from having to remember a pill every day. </p>
<p>LARC methods include the contraceptive implant and hormonal intrauterine device (IUD), available in Australia since the early 2000s, and copper IUDs which have been around since the 1970s. </p>
<p>Global and local institutions from the <a href="http://apps.who.int/iris/bitstream/10665/75161/1/WHO_RHR_HRP_12.20_eng.pdf">World Health Organisation</a> to the <a href="https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Long-acting-reversible-contraception-(C-Gyn-34)-Review-July-2017.pdf?ext=.pdf">Royal Australian and New Zealand College of Obstetricians and Gynaecologists</a> and <a href="https://www.fpnsw.org.au/sites/default/files/assets/fpaa_larc_statement_october_2014.pdf">family planning organisations</a> advocate for increased access to LARCs. But there is still a lack of awareness and negative perceptions about these methods.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/few-australian-women-use-long-acting-contraceptives-despite-their-advantages-44896">Few Australian women use long-acting contraceptives, despite their advantages</a>
</strong>
</em>
</p>
<hr>
<h2>What are the options?</h2>
<p>Unlike condoms, which need to be used every time with sex, or the pill, which must be taken every day, LARC doesn’t require any action after placement in the body and is immediately reversible.</p>
<p><strong>Arm implant</strong></p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217379/original/file-20180503-153878-195rezk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Implanon implants are placed in the arm.</span>
<span class="attribution"><span class="source">Family planning NSW.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The contraceptive implant available in Australia, known under the brand name Implanon, is a 4cm flexible rod, placed under the skin of the upper inner arm. It slowly releases a progestogen hormone called etonogestrel over a three-year period. </p>
<p>Two-rod implants are available in other countries, including New Zealand. These last for up to five years. </p>
<p>Implants work by preventing the release of an egg each month from the ovary. They also thicken the mucus at the cervix to prevent sperm reaching the uterus. </p>
<p>Implants are more than 99.9% effective, which means <a href="https://www.ncbi.nlm.nih.gov/pubmed/21477680">fewer than one in every 1,000 women</a> using the implant will become pregnant in a year.</p>
<p>Implants are <a href="http://www.pbs.gov.au/medicine/item/8633J">subsidised by the Pharmaceutical Benefits Scheme</a> so patients pay A$39.50 for the device (A$6.40 concession). </p>
<p><strong>Interuterine device</strong></p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/216983/original/file-20180501-135825-dn32ol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/216983/original/file-20180501-135825-dn32ol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216983/original/file-20180501-135825-dn32ol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216983/original/file-20180501-135825-dn32ol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216983/original/file-20180501-135825-dn32ol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216983/original/file-20180501-135825-dn32ol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216983/original/file-20180501-135825-dn32ol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hormonal IUDs sit in the uterus.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/mirkmirk/31140095680/">Sarah Mirk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>The hormonal IUD, known under the brand name Mirena, is a plastic T-shaped device placed in the uterus. It releases a low dose of a progestogen hormone called levonorgestrel for up to five years. </p>
<p>Copper devices don’t emit hormones and last between five years (for the Load-375 IUD) and ten years (for the Copper T380). </p>
<p>IUDs mainly work by interfering with sperm movement, which stops them fertilising an egg. Sometimes they work by preventing implantation of a fertilised egg, but they never have an effect after implantation has occurred. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/216985/original/file-20180501-135803-19n98dv.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/216985/original/file-20180501-135803-19n98dv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=766&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216985/original/file-20180501-135803-19n98dv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=766&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216985/original/file-20180501-135803-19n98dv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=766&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216985/original/file-20180501-135803-19n98dv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=963&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216985/original/file-20180501-135803-19n98dv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=963&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216985/original/file-20180501-135803-19n98dv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=963&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Copper IUDs don’t contain hormones.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Anticonceptiespiraal_zonder_hormonen.png">AnnaMartheK</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Hormonal IUDs also thicken the cervical mucus to prevent sperm reaching the uterus and can, less commonly, prevent ovulation. </p>
<p>While the hormonal IUD is slightly more effective than the copper device, especially in young women, both are more than <a href="https://www.ncbi.nlm.nih.gov/pubmed/25601350">99% effective</a>. This means fewer than one in every 100 women using IUDs become pregnant each year.</p>
<p>The hormonal IUD is also <a href="http://www.pbs.gov.au/medicine/item/8633J">subsidised by the PBS</a>, so patients pay A$39.50 for the device (A$6.40 concession). Copper IUDs aren’t listed on the PBS and <a href="https://www.choice.com.au/health-and-body/reproductive-health/contraception/buying-guides/contraception">cost up to A$150</a>. </p>
<p>There are specific Medicare rebates for the insertion and removal of implants and the insertion of an IUD. Patients may also pay a gap fee for the consultations.</p>
<h2>Choosing contraception</h2>
<p>As a family planning doctor, I know that finding the best contraceptive to suit a woman’s individual circumstances is based on a multitude of factors from side-effects to cost and personal preference. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-the-options-for-birth-control-18613">Explainer: what are the options for birth control?</a>
</strong>
</em>
</p>
<hr>
<p>While some women prefer a contraceptive they can stop and start themselves or one that is hormone-free, others like a method they can forget about from day to day. </p>
<p>Some women want a contraceptive that can eliminate their menstrual bleeding, while others prefer a regular bleeding pattern. </p>
<p>Individual experience is hugely variable: </p>
<blockquote>
<p>I’ve just had my third Implanon taken out. So it’s been nine years. I think I got one taken out early, but yeah, nine years of Implanon. I just loved the convenience of that and the price… – <a href="https://www.racgp.org.au/afp/2016/october/australian-women%E2%80%99s-experiences-of-the-subdermal-contraceptive-implant-a-qualitative-perspective/">Chloe (30s)</a></p>
<p>I kind of I feel like a, you’re being microchipped or something… I think it’s amazing technology … but I just, I don’t think I could do it. – <a href="https://www.ncbi.nlm.nih.gov/pubmed/26941357">Maya (20s)</a></p>
</blockquote>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216993/original/file-20180501-135814-l8nuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216993/original/file-20180501-135814-l8nuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216993/original/file-20180501-135814-l8nuy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216993/original/file-20180501-135814-l8nuy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216993/original/file-20180501-135814-l8nuy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216993/original/file-20180501-135814-l8nuy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216993/original/file-20180501-135814-l8nuy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman’s contraceptive needs may change throughout her life.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/vBetZA2-bJg">Tanja Heffner</a></span>
</figcaption>
</figure>
<p>Informed choice is fundamental. What suits a woman as a teenager may be very different to what suits her in her 30s or late 40s. Informed choice needs to be based on evidence that includes the pros as well as the cons of all options.</p>
<h2>What are the pros of LARC?</h2>
<p>There are very <a href="http://www.fsrh.org/standards-and-guidance/uk-medical-eligibility-criteria-for-contraceptive-use">few medical reasons</a> preventing women of any reproductive age using LARC. </p>
<p>None of the implants or intrauterine devices contain oestrogen, so they avoid the risk (<a href="https://theconversation.com/dont-panic-about-the-pill-its-safer-than-driving-to-work-42325">albeit very small</a>) of venous blood clots associated with the combined oral contraceptive pill or the vaginal ring. </p>
<p>LARC methods don’t rely on remembering to take a daily pill or stopping to put on a condom. Once in place, they don’t require a visit to the doctor or any ongoing costs. </p>
<p>The hormonal IUD thins out the lining of the uterus and is highly effective at reducing menstrual blood loss. It is <a href="https://www.safetyandquality.gov.au/our-work/clinical-care-standards/heavy-menstrual-bleeding/">recommended</a> as a first-line option for women with heavy menstrual bleeding, which can result in iron deficiency and anaemia. </p>
<p>It can also be <a href="https://www.ncbi.nlm.nih.gov/pubmed/20618247">effective in controlling the symptoms of endometriosis</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-happens-to-endometriosis-when-youre-on-the-pill-89035">What happens to endometriosis when you're on the pill?</a>
</strong>
</em>
</p>
<hr>
<p>The copper IUD can be used as a highly effective method of emergency contraception when inserted within five days of unprotected intercourse. It can then be continued for up to ten years.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216994/original/file-20180501-135851-1fdzi0m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216994/original/file-20180501-135851-1fdzi0m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216994/original/file-20180501-135851-1fdzi0m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216994/original/file-20180501-135851-1fdzi0m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216994/original/file-20180501-135851-1fdzi0m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216994/original/file-20180501-135851-1fdzi0m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216994/original/file-20180501-135851-1fdzi0m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The set and forget aspect of LARC appeals to many users.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/w9hM8sTVPvE">Matthew Miner</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>What about the cons?</h2>
<p>Insertion of an implant just under the skin of the arm requires a simple procedure using local anaesthetic.</p>
<p>An IUD is inserted into the uterus through the cervix, which can be uncomfortable. Most women have their IUD inserted using local anaesthetic but some choose to have it put in under light sedation. </p>
<p>There are <a href="https://www.fsrh.org/news/updated-clinical-guideline-published-contraception-for-women/">some complications</a> associated with these procedures, including a small risk of infection. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/reporting-a-few-cases-of-negative-side-effects-from-long-acting-contraceptives-is-alarmist-and-damaging-89074">Reporting a few cases of negative side effects from long-acting contraceptives is alarmist and damaging</a>
</strong>
</em>
</p>
<hr>
<p>Once in place, the implant can cause unpredictable and sometimes troublesome vaginal bleeding. The copper IUD can be associated with heavier and longer-lasting periods. </p>
<p>Women using an implant or hormonal IUD can have hormonal side effects such as headache, acne, mood changes, or reduced libido. </p>
<p>While it’s impossible to predict who will experience side-effects, it’s important all women are aware of this risk and know to seek medical advice if needed.</p>
<h2>How common are they?</h2>
<p>The uptake of implants and IUDs in Australia has increased <a href="https://www.ncbi.nlm.nih.gov/pubmed/14696713">from 2.3% in 2001/02</a> to <a href="https://www.ncbi.nlm.nih.gov/pubmed/27373543">11.0% in 2012/13</a>.</p>
<p>But lack of awareness and persistent misperceptions prevent some women from considering this option. Some women (and <a href="http://onlinelibrary.wiley.com/wol1/doi/10.1111/j.1479-828X.2010.01136.x/abstract">sometimes their doctors</a>) erroneously believe an IUD cannot be used by young women or women who have not had children, or that LARC will cause a problem with future fertility. </p>
<p>Finding a clinic nearby to put in an IUD or an implant can also be difficult. To ensure equitable access, we need to increase the number of doctors and nurses inserting LARC across Australia through enhanced training programs and improved remuneration.</p>
<p>While the pill continues to serve many women well, and its introduction over 50 years ago is rightly regarded as a significant step in women’s empowerment, the highly effective (and cost-effective) LARC methods are increasingly chosen by women from adolescence through to menopause across the globe.</p><img src="https://counter.theconversation.com/content/92116/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>As part of her role at Family Planning NSW, Deborah Bateson has attended advisory committees and spoken independently at educational events sponsored by Bayer Healthcare and MSD. She has never been personally remunerated for these services; she has been supported to attend conferences by Bayer Healthcare.</span></em></p>Unlike condoms, which need to be used every time with sex, or the pill, which must be taken every day, LARC doesn’t require any action after placement in the body and is immediately reversible.Deborah Bateson, Clinical Associate Professor, Discipline of Obstetrics, Gynaecology and Neonatology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/814532017-07-27T03:02:13Z2017-07-27T03:02:13ZContraceptive use in Nigeria is incredibly low. A lack of knowledge may be why<figure><img src="https://images.theconversation.com/files/179605/original/file-20170725-23039-xtft18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Contraceptives lie at the heart of proper family planning but in Nigeria uptake has been slow.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The importance of <a href="https://www.usaid.gov/sites/default/files/documents/1864/Glob%20Health%20Sci%20Pract-2016-Starbird-GHSP-D-15-00374-508ct_final.pdf">family planning</a> in addressing a range of challenges in developing countries is now widely accepted. Family planning is a key factor in achieving the <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">Sustainable Development Goals</a>. And getting it right can help countries in meeting related targets such as education, particularly for women and girls.</p>
<p>If done properly it can <a href="http://www.urbangateway.org/sites/default/ugfiles/Levels,%20Trends%20and%20Differentials.pdf">prevent</a> unintended and high risk pregnancies that often lead to the deaths of mothers and babies. It’s important for other reasons too: it can reduce women’s dependency by allowing them more opportunities to work. And lower population growth, combined with a good political climate, can boost <a href="http://www.nature.com/news/development-slow-down-population-growth-1.19415">economic development</a>.</p>
<p>Contraceptives lie at the heart of proper family planning. But its use can be shaped by several factors. This includes cultural norms and values as well as the desires and decisions of couples. <a href="https://www.ncbi.nlm.nih.gov/pubmed/17140337">Myths and misconceptions</a> also play a role, including beliefs that people who use contraceptives end up with <a href="https://globaljournals.org/GJMR_Volume11/1-Contraceptive-Practices-Among-Women-in-Rural.pdf">health problems or permanent infertility</a>, or, at one extreme, that contraceptives reduce sexual urge, and at the other that they increase promiscuity among women. </p>
<p>Other contributing factors include low <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835625/">access to health care facilities</a> and the <a href="http://www.bioline.org.br/request?rh06037">patriarchal nature of societies</a>. </p>
<p>Nigeria has made no progress in improving the use of <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">contraceptives for the past 10 years</a>. Contraceptive use in the country is incredibly low. </p>
<p>The biggest contributor to the low uptake has been a lack of knowledge about the various available options, combined with misconceptions about the use of contraceptives. </p>
<p>But understanding what we mean by “knowledge” is key to unlocking Nigeria’s problem. We all accept that human behaviour is generally affected by what people know. A reasonable deduction would therefore be that knowledge about contraception should be an important predictor of contraceptive use. The reasonable assumption would be that the more people know about contraceptives, the more they would use them.</p>
<p>Nigeria’s <a href="http://microdata.worldbank.org/index.php/catalog/2014">2013 demographic health survey</a> showed that this isn’t the case. About 85% of women and 95% of men reported knowing a contraceptive method. But just 15% were using it. The unmet needs of women wishing to stop or delay births by not using contraception is 16%.</p>
<p>There’s nothing to suggest that the situation has improved since the 2013 report. This is clear from <a href="http://data.un.org/Data.aspx?q=Nigeria+growth&d=WDI&f=Indicator_Code%3ASP.POP.GROW%3BCountry_Code%3ANGA">Nigeria’s continued rates of population growth</a> as well as <a href="https://www.unicef.org/nigeria/children_1926.html">maternal and infant deaths</a>.</p>
<h2>Poor state of affairs in Nigeria</h2>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0010782414006969">Only 15% of Nigerian women</a> aged 15-49 use contraception for limiting and spacing of birth. A Nigerian woman gives birth to an average of <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">5.5 children in her lifetime</a>. The country’s annual population <a href="http://data.un.org/Data.aspx?q=Nigeria+growth&d=WDI&f=Indicator_Code%3ASP.POP.GROW%3BCountry_Code%3ANGA">growth rate as at 2015 was 2.6%</a>. </p>
<p>Algeria provides a useful counterpoint. More than half – 57% – of married women are using contraception and a woman will give birth to an average of <a href="http://worldpopulationreview.com/countries/algeria-population/">3 children in her lifetime</a>. The north African country’s <a href="http://www.gdpinflation.com/2014/09/algeria-population-from-1960-to-2014.html">annual population growth rate is 1.89</a>. </p>
<p>In Sweden, contraceptive use is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439158/">75%</a>. A Swedish woman will give birth to an average of <a href="http://www.pregnantpause.org/numbers/fertility.htm">1.6 children</a> and the country’s <a href="http://data.worldbank.org/indicator/SP.POP.GROW">population growth rate is 1.1</a>.</p>
<p>So what is Nigeria doing wrong? And how can it be fixed?</p>
<h2>What’s missing</h2>
<p>Knowledge of contraception means knowing at least one of the methods. Modern contraceptive methods include female sterilisation, male sterilisation, the pill, the intrauterine device (IUD), injectables, implants, male condoms, female condoms, the diaphragm, foam/jelly, the lactational amenorrhea method, and traditional methods include periodic <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">abstinence and withdrawal</a>.</p>
<p>On average, a Nigerian woman or man aged 15-49 knows about <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">5 out of the 15 methods of contraceptives</a>. </p>
<p>On top of this, the most common methods cited were those that carry the highest risks of pregnancy. The most common method women cited was the pill (71%) which has a failure rate of 9% and can lead to nine <a href="https://www.ncbi.nlm.nih.gov/pubmed/22590895">unintended pregnancies</a> per one hundred women a year. </p>
<p>For men, the most common method cited was the male condom (91%), <a href="https://www.ghc.org/kbase/topic.jhtml?docId=hw190504spec">which has a failure rate of 18% </a>. This can lead to 18 unintended pregnancies per one hundred women in a year. </p>
<p>Among the least known methods by both men and women in Nigeria was the long acting reversible implants method which can last between three to five years for women who use it. <a href="http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/Implant">Implants have a 0.05% failure rate</a>. However, only 17.9% men and 24.7% women knew about it. </p>
<h2>The consequences</h2>
<p>If Nigeria continues with the current trends in contraceptive use and fertility, the population will <a href="http://www.urbangateway.org/sites/default/ugfiles/Levels,%20Trends%20and%20Differentials.pdf">continue to grow exponentially in the next 10 to 20 years</a>. </p>
<p>The consequences of this will be profound. The population will be a highly dependent one with few productive and more dependent people because of the age structure of exponential population growth. Also, health inequities will worsen. Already limited infrastructure will be stretched while rapid urbanisation will shrink service provision, leading to further social and economic challenges.</p>
<p>Nigeria needs to urgently rethink family planning programmes. In particular, it needs to focus on ensuring that people know more about the array of available contraceptives, the most effective types and how they can access them.</p>
<p>An initiative like this should also aim to reduce perceptions based on myths and misconceptions. Algeria has successfully plugged family planning gaps using an <a href="http://countrystudies.us/algeria/61.htm">integrated approach</a> of contraceptives availability, educational campaigns and partnering with religious groups.</p>
<p>Only a concerted effort can turn the situation around in Nigeria and narrow the existing knowledge gap.</p><img src="https://counter.theconversation.com/content/81453/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Funke Fayehun does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nigeria must reduce its population growth to increase the quality of life for people in the country. A better knowledge of contraceptives can help achieve this.Funke Fayehun, Senior lecturer, University of Ibadan, University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/575462016-04-27T10:07:15Z2016-04-27T10:07:15ZHow limiting women’s access to birth control and abortions hurts the economy<p>Reproductive health isn’t <a href="https://www.guttmacher.org/united-states/abortion/demographics">just about abortions</a>, despite all the attention they get. It’s also about access to family planning services, contraception, sex education and much else.</p>
<p>Such access lets women control the timing and size of their families so they have children when they are financially secure and emotionally ready and can finish their education and advance in the workplace. After all, <a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">having children is expensive</a>, costing US$9,000 to $25,000 a year. </p>
<p>And that’s why providing women with a full range of reproductive health options is good for the economy at the same time as being essential to the financial security of women and their families. Doing the opposite threatens not only the physical health of women but their economic well-being too.</p>
<p>The Supreme Court <a href="https://www.oyez.org/cases/1991/91-744">acknowledged</a> as much in 1992, stating in Planned Parenthood of Southeastern Pennsylvania v. Casey:</p>
<blockquote>
<p>The ability of women to participate equally in the economic and social life of the nation has been facilitated by their ability to control their reproductive lives.</p>
</blockquote>
<p>However, it seems that state and federal legislators, certain politicians running for president as well as some conservative Supreme Court justices have forgotten the meaning of this sweeping language.</p>
<p>As a consequence, the right to control their reproductive health has become <a href="http://thinkprogress.org/health/2013/05/08/1979831/women-struggle-afford-abortion/">increasingly illusory</a> for many women, particularly the poor.</p>
<h2>The economics of contraception</h2>
<p>With some conservative politicians dead set on limiting access to abortion, you’d assume that they would be for policies that help women avoid unintended pregnancies. But <a href="http://www.motherjones.com/politics/2012/02/republican-war-birth-control-contraception'">conservative attacks on birth control</a> are escalating, even though <a href="http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf">99 percent of sexually active women</a> have used <a href="https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states">some form such as an intrauterine device (IUD), patch or pill</a> at least once. </p>
<p>In addition to its widely recognized health and autonomy benefits for women, contraception <a href="http://www.theatlantic.com/health/archive/2014/07/the-broader-benefits-of-contraception/373856">directly boosts the economy</a>. In fact, research shows access to the pill <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684076/">is responsible</a> for a third of women’s wage gains since the 1960s. </p>
<p>And this benefit extends to their kids. Children born to mothers with access to family planning <a href="http://www.nber.org/papers/w19493.pdf">benefit from a 20 to 30 percent increase</a> in their own incomes over their lifetimes, as well as boosting college completion rates. </p>
<p>Not surprisingly, in a survey, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23021011">77 percent of women</a> who used birth control reported that it allowed them to better care for themselves and their families, while large majorities also reported that birth control allowed them to support themselves financially (71 percent), stay in school (64 percent) and help them get and keep a job (64 percent). </p>
<p>Still, there is a class divide in contraception access, as evidenced by disparities in the 2011 rate of unintended pregnancies. While the <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1506575">overall rate</a> fell to 45 percent (from 51 percent in 2008), the figure for women living at or below the poverty line was <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/FB-Unintended-Pregnancy-US.pdf">five times that of women</a> at the highest income level (although also decreasing).</p>
<p>One reason for this disparity is the <a href="http://www.thenation.com/article/why-does-best-birth-control-cost-entire-months-wages/">cost of birth control</a>, particularly for the most effective, long-lasting forms. For instance, it typically costs over $1,000 for an IUD and the procedure to insert it, amounting to <a href="http://www.jahonline.org/article/S1054-139X(13)00054-2/pdf">one month’s full-time pay</a> for a minimum wage worker. </p>
<p>These costs are significant, given that the <a href="https://www.guttmacher.org/sites/default/files/pdfs/pubs/fulfill.pdf">average American woman wants</a> two children and will thus need contraception for at least three decades of her life. Unfortunately, <a href="http://rooseveltinstitute.org/wp-content/uploads/2015/11/Breaking-the-Cycle-of-Poverty-Expanding-Access-to-Family-Planning.pdf">publicly funded family planning</a> meets only 54 percent of the need, and these funding streams are under constant attack by conservatives.</p>
<p>Not surprisingly, <a href="http://www.scotusblog.com/2015/12/symposium-womens-compelling-need-for-contraception-met-by-insurers-not-objecting-employers/">health insurance makes a difference</a>, and women with coverage are much more likely to use contraceptive care. The <a href="http://nwlc.org/resources/zubik-v-burwell-non-profit-objecting-employers-should-not-be-allowed-to-make-it-harder-for-women-to-access-critical-birth-control-coverage/">Affordable Care Act is responsible</a> for part of the drop in unintended pregnancies – it expanded contraception coverage to around 55 million women with private insurance coverage. </p>
<p>Yet this coverage is also at risk for millions of employees and their dependents who work for employers claiming a religious objection. In Burwell v. Hobby Lobby, the <a href="http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf">Supreme Court concluded</a> that a for-profit company cannot only profess religious beliefs but also impose those beliefs on their employees by denying them certain forms of contraception. The <a href="http://kff.org/womens-health-policy/issue-brief/round-2-on-the-legal-challenges-to-contraceptive-coverage-are-nonprofits-substantially-burdened-by-the-accommodation/">Obama administration has issued regulations</a> allowing religious employers to opt out of offering contraceptive coverage. Affected employees are then covered directly by their insurers.</p>
<p>This is not enough for some. In March, the Supreme Court heard oral arguments in the case of <a href="http://www.scotusblog.com/case-files/cases/zubik-v-burwell">Zubik v. Burwell</a>, in which several religious <a href="http://kff.org/womens-health-policy/issue-brief/contraceptive-coverage-at-the-supreme-court-zubik-v-burwell-does-the-law-accommodate-or-burden-nonprofits-religious-beliefs/">nonprofits assert</a> that even the act of seeking an accommodation from the law burdens their religious consciences. </p>
<p>These religious groups argue in part that women can get their birth control from other sources, such as federally funded family planning centers. Yet at the same time, <a href="http://time.com/4264955/contraceptive-coverage/">conservatives are on a mission to slash that funding</a>, particularly for Planned Parenthood, which provides sexual and reproductive health care to almost five million people a year.</p>
<p>This makes no economic sense. Publicly funded family planning programs <a href="https://www.guttmacher.org/news-release/2015/publicly-funded-family-planning-yields-numerous-positive-health-outcomes-while">help women avoid about two million unintended pregnancies</a> a year and save the government billions of dollars in health care costs. The net savings to government are $13.6 billion. For every $1 invested in these services, the government saves $7.09.</p>
<h2>Sex education and the economic ladder</h2>
<p>Another key to reproductive health – and one that isn’t discussed enough – is sexual education for teenagers. </p>
<p>For years, the public has spent over $2 billion on abstinence-only programs, which not only <a href="http://www.jahonline.org/article/S1054-139X(05)00467-2/fulltext?mobileUi=0">fail to reduce teen birth rates</a> but also reinforce gender stereotypes and are rife with misinformation. Low-income minority teens <a href="http://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=1084&context=bjalp">are particularly subject</a> to these programs.</p>
<p>Teens without knowledge about their sexual health <a href="http://www.advocatesforyouth.org/publications/publications-a-z/597-abstinence-only-until-marriage-programs-ineffective-unethical-and-poor-public-health">are more likely</a> to get pregnant and less likely to work, spiraling them to the bottom of the economic ladder. </p>
<p>President Obama’s <a href="http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&FeatureID=2438">proposed 2017 budget would eliminate federal funding</a> for abstinence-only sex education and instead fund only comprehensive sexual education, which is age-appropriate and medically accurate. However, <a href="http://www.motherjones.com/mojo/2016/02/state-of-teen-sex-america-chart-abstinence">Congress has rejected</a> the president’s prior proposed cuts and the same result is likely for 2017. </p>
<h2>Access to abortion</h2>
<p>Then there’s the issue of abortion. Let’s start with the cost.</p>
<p><a href="http://www.nwlc.org/sites/default/files/pdfs/reproductive_health_is_part_of_the_economic_health_of_women_5.29.15pdf.pdf">Half of women who obtain an abortion</a> pay more than one-third of their monthly income for the procedure.</p>
<p>Costs rise significantly the longer a woman must wait, either because state law requires it or she needs to save up the money – or both. Studies show that women <a href="http://www.nytimes.com/2013/06/16/magazine/study-women-denied-abortions.html?_r=0">who cannot access abortion</a> are <a href="http://rhtp.org/abortion/documents/TwoSidesSameCoinReport.pdf">three times more likely</a> to fall into poverty than women who obtained abortions.</p>
<p>In addition to the financial burden, <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">many states are enacting laws</a> designed to limit abortion access. These laws hit low-income women particularly hard. From 2011 to 2015, <a href="https://www.guttmacher.org/article/2016/01/2015-year-end-state-policy-roundup">31 states have enacted</a> 288 such laws, including waiting periods and mandatory counseling sessions. </p>
<p>Moreover, <a href="https://www.guttmacher.org/sites/default/files/pdfs/spibs/spib_TRAP.pdf">24 states have enacted so-called TRAP laws</a> (targeted regulation of abortion providers), which medical experts say go far beyond what is needed for patient safety and impose needless requirements on doctors and abortion facilities, <a href="http://www.acog.org/About-ACOG/News-Room/News-Releases/2013/ACOG-and-AMA-File-Amicus-Brief">such as requiring facilities</a> to have the same hallway dimensions as a hospital. </p>
<p>In March, the Supreme Court heard arguments in a case <a href="http://www.scotusblog.com/case-files/cases/whole-womans-health-v-cole/">challenging a Texas TRAP law</a>, <a href="http://www.reproductiverights.org/case/whole-womans-health-v-hellerstedt">Whole Women’s Health v. Hellerstedt</a>. If the court upholds the law, the entire state of Texas will be left with only 10 abortion providers.</p>
<p>A <a href="http://www.scotusblog.com/wp-content/uploads/2015/09/14-50928-CV0.pdf">lower federal appeals court stated</a> in the Texas case that travel distances of more than 150 miles one way are not an “undue burden” and are thus constitutional. This, I would argue, shows a <a href="http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2446644">complete lack of understanding</a> regarding the difficulties that poverty – especially rural poverty – imposes. Traveling long distances adds additional costs to an already expensive medical procedure. </p>
<p>The court’s decision is expected in June. <a href="http://www.slate.com/articles/news_and_politics/supreme_court_dispatches/2016/03/in_oral_arguments_for_the_texas_abortion_case_the_three_female_justices.html">Observers fear</a> that the court could split 4-4, which would leave the Texas law intact. </p>
<h2>The Hyde Amendment</h2>
<p>Another way in which U.S. policy on abortions <a href="https://www.americanprogress.org/issues/women/news/2013/05/10/62875/how-the-hyde-amendment-discriminates-against-poor-women-and-women-of-color">exacerbates economic inequality, especially for women of color</a>, is through the ban on federal funding – which some aspiring politicians <a href="http://www.motherjones.com/mojo/2016/02/donald-trump-really-doesnt-understand-how-federal-funding-works-planned-parenthood-0">seem to have forgotten</a> is still in place.</p>
<p>It has been so since the <a href="http://billmoyers.com/content/five-facts-you-should-know-about-the-hyde-amendment/">1976 enactment of the Hyde Amendment</a>, which prevents federal Medicaid funds from being used for abortions except in cases of rape, incest or when the life of the mother is at risk. The Affordable Care Act does many wonderful things for women’s health, but it also <a href="http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-in-medicaid-marketplace-plans-and-private-plans/">extends the Hyde Amendment</a> through its expansion of Medicaid, and it allows states to ban abortion coverage in their private exchanges. </p>
<p>Denying poor women coverage under Medicaid contributes to the unintended birth rates that are <a href="https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states">seven times higher</a> for poor women than high-income women. </p>
<h2>Economic and reproductive health</h2>
<p>Politicians cannot promise to grow the economy and simultaneously limit access to abortion, birth control and sexual education. Our nation’s economic health and women’s reproductive health are linked.</p>
<p>And as Hillary Clinton <a href="http://www.politifact.com/truth-o-meter/statements/2016/apr/15/hillary-clinton/hillary-clinton-says-democratic-debate-moderators-/">correctly noted</a> recently, it’s an issue that deserves more attention in the presidential campaign – and hasn’t received enough.</p><img src="https://counter.theconversation.com/content/57546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michele Gilman is affiliated with the ACLU of Maryland and the Women's Law Center of Maryland.</span></em></p>Providing women with a range of reproductive health options – from abortions to IUDs – is not only essential for their financial security but good for the economy as well.Michele Gilman, Venable Professor of Law, University of BaltimoreLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/448962015-09-27T19:21:30Z2015-09-27T19:21:30ZFew Australian women use long-acting contraceptives, despite their advantages<figure><img src="https://images.theconversation.com/files/95115/original/image-20150917-32615-chxckk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Long-acting reversible contraception such as intrauterine devices don't require women who use them to do anything else to prevent pregnancy. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/mirkmirk/16670919389/">Sarah Mirk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Few Australian women use long-acting reversible contraception, despite its advantages over other methods. These contraceptives offer women long-term, cost-effective, “fit-and-forget” contraception.</p>
<p>Long-acting reversible contraception (LARC) includes intrauterine devices (IUDs) and implants that are usually inserted in the upper arm. In contrast to other commonly used contraceptives, such as the pill and condoms, LARC don’t require women who use them to do something to prevent pregnancy daily or every time they have sex. </p>
<p>Intervention is required only when a decision is made to stop their use, and <a href="http://dx.doi.org/10.1016/j.contraception.2006.09.010">fertility is restored</a> when the contraception is removed.</p>
<h2>Good but under-used</h2>
<p>This type of contraception is highly effective for between three and ten years. Women using these methods have <a href="http://www.ranzcog.edu.au/documents/doc_download/2050-long-acting-reversible-contraception-c-gyn-34.html">less chance of unintended pregnancy</a> compared to women using other contraceptives. </p>
<p>In fact, along with sterilisation, these are <a href="http://www.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm#How-effective-are-birth-control-methods">the most effective means of contraception</a>. This is because unlike other methods – such as the oral contraceptive pill, diaphragm, rings and condoms – whose effectiveness depends on correct and consistent use, compliance isn’t an issue.</p>
<p>Long-acting contraception is <a href="http://whqlibdoc.who.int/hq/2008/WHO_RHR_08.19_eng.pdf.">suitable for most women</a> including the young, those who’ve never given birth, are breastfeeding or have recently given birth, and those with chronic health conditions. It’s also suitable for use just before menopause, and <a href="http://austinpublishinggroup.com/obstetrics-gynecology/fulltext/ajog-v1-id1027.php">appropriate</a> for women who should avoid oestrogen. </p>
<p>Despite these apparent benefits, <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">our research</a> shows Australian women don’t use these contraceptive methods very much when compared to women in other high-income countries.</p>
<p>Even though most of the 1,131 Australian women <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">we surveyed</a> had heard of IUD and implants, only 4% to 8% reported using these methods compared with <a href="http://onlinelibrary.wiley.com.ezproxy.lib.monash.edu.au/doi/10.1363/46e1914/epdf">10% to 32% in Europe and 10% in the United States</a>. </p>
<p>On the whole, our respondents thought these contraceptive methods were unreliable and said they were unlikely to consider using them. The findings of <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">our study</a> suggest women in Australia may not be using LARC due to misperceptions about side effects, suitability and cost. </p>
<h2>Possible misunderstandings</h2>
<p>Concerns about the side effects and safety of LARC may reflect <a href="http://dx.doi.org/10.5694/mja12.11832">women’s understanding of the risks of infection and infertility</a> associated with older intrauterine devices. But modern long-acting contraception has been developed to overcome these early problems. They’re <a href="http://dx.doi.org/10.1097%2FAOG.0b013e31828b63a0">safe</a> and US studies show they have <a href="http://dx.doi.org/10.1097%2FAOG.0b013e31821188ad">higher rates of continuation and satisfaction</a> than other contraceptive methods. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The effectiveness of long-acting contraceptive methods doesn’t depend on correct and consistent use.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/hey__paul/6980584656/">Hey Paul Studios/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Religious beliefs may also influence choice of contraception away from long-acting options. <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">We found</a> women who said religion was important in their fertility choices were less likely to consider long-acting contraceptive methods as reliable. And they were less likely to consider using them. </p>
<p>What’s more, UK research also shows doctors may not comply with patient requests for certain methods of contraception because of <a href="http://jfprhc.bmj.com/content/34/1/47.long">their own personal religious beliefs</a>.</p>
<p>Interestingly, <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">our research team</a>, along with others in <a href="http://dx.doi.org/10.5694/mja14.00011">Australia</a> and the <a href="http://dx.doi.org/10.1097%2FAOG.0b013e31821188ad">United States</a>, found women who’ve had a pregnancy or an abortion are more likely to think long-acting contraception is reliable and consider using it. </p>
<p>It’s likely that women who have experienced a pregnancy or, especially, an abortion are more motivated to obtain more effective contraception and avoid further unintended pregnancies. And doctors are likely to pay greater attention to these women’s contraceptive needs. </p>
<h2>Myriad barriers</h2>
<p><a href="http://dx.doi.org/10.3109/13625187.2015.1052394">We’ve also found</a> that <a href="http://dx.doi.org/10.1016/j.ajog.2012.02.014">men tend to have</a> less knowledge of these contraceptive methods and to perceive them as being <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">less reliable</a>. This is likely due to the fact that women are the primary users of LARC and that men may receive little contraception education. Still, the <a href="http://dx.doi.org/10.1016/j.contraception.2011.04.018">attitudes of male partners</a> are important predictors of contraceptive use. </p>
<p><a href="http://www.fpv.org.au/assets/LARCstatementSHFPAFINAL.pdf">The cost</a> of long-acting contraception could be a barrier for some Australian women. <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">We found</a> women who lived in socioeconomically advantaged areas were more likely to think of these contraceptive methods as reliable and consider using them than women who lived in disadvantaged areas. </p>
<p>It may be that the former have better health and access to health services and products, as well as money to spend on contraception. While implants and IUDs are subsidised by the Pharmaceutical Benefits Scheme, there are high costs – paid by the patient – for the insertion procedure. But despite their high initial cost, long-acting contraceptives <a href="http://dx.doi.org/10.1016/j.contraception.2008.08.003">are not expensive over the longer term</a>. They cost about the same as the oral contraceptive pill over equivalent periods of use. </p>
<p><a href="http://dx.doi.org/10.1016/j.whi.2010.07.005">Doctors</a> may be reluctant to prescribe these types of contraceptives because of uncertainty about their suitability. And they may have not received training on insertion. Indeed, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23992177">a 2013 Australian study</a> concluded doctors’ beliefs were the most important barrier to women using these contraceptive methods. </p>
<p>To help women make the right contraceptive choice for their needs, we need to provide accurate, up-to-date information to them, their male partners and their doctors. And we need to ensure that cost doesn’t prevent a woman from using the contraceptive method best suited to her.</p><img src="https://counter.theconversation.com/content/44896/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors, including Sara Holton, are investigators on the 'Understanding fertility management in contemporary Australia' study which was supported by an Australian Research Council Linkage Project Grant (LP100200432) with funding and in-kind contributions from Family Planning Victoria, Melbourne IVF, The Royal Women’s Hospital, and the Victorian Department of Health</span></em></p><p class="fine-print"><em><span>Heather Rowe receives funding from the National Health and Medical Research Council, the Australian Government, the Australian Research Council, Australian Rotary Health, not-for profit organisations and philanthropic trusts. </span></em></p><p class="fine-print"><em><span>Jane Fisher currently receives funding from the National Health and Medical Research Council, the Australian Research Council, the Australian Department of Social Services, the Australian Department of Health, the Victorian Department of Health and Human Services, Jean Hailes for Women's Health, Family Planning Victoria, Women's Health Victoria, Monash Health, the Australian Federation of Medical Women, the Parenting Research Center, Melbourne IVF, Grand Challenges Canada, Australian Rotary Health; the L and H Hecht Trust, the Jack Brockhoff Foundation and the Prostate Cancer Foundation of Australia .
Jane Fisher is President-elect of the International Marce Society for Perinatal Mental Health, she chairs the Psychosocial and Epidemiological Research in Reproduction Group for the Royal Women’s Hospital and Melbourne IVF and sits on the Royal Women’s Hospital Research Committee (2003 -), the Epworth Healthcare Human Research Ethics Committee (2009-) and the Masada Private Hospital Patient Care Review Committee (2003-). She is a member of the NHMRC Mental Health and Parenting Expert Advisory Group (2014-) and of the International Board of Advisors, Research and Training Centre for Community Development Hanoi, Vietnam. She has been an invited temporary technical adviser to WHO Departments of Reproductive Health and Research, Mental Health and Substance Use and Maternal, Newborn, Child and Adolescent Health and Development since 2005.</span></em></p><p class="fine-print"><em><span>Maggie Kirkman receives funding from the Australian Research Council, the National Health and Medical Research Council, Jean Hailes for Women's Health, Family Planning Victoria, Women's Health Victoria, Monash Health, and the Australian Federation of Medical Women.</span></em></p>Few Australian women use long-acting reversible contraception, despite its advantages over other methods. These contraceptives offer women long-term, cost-effective, “fit-and-forget” contraception.Sara Holton, Research Fellow - Women's Health, Monash UniversityHeather Rowe, Senior Research Fellow, Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash UniversityJane Fisher, Professor & Director, Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash UniversityMaggie Kirkman, Senior Research Fellow, Jean Hailes, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.