Contraceptive implants: long acting and provider dependent contraception raises concerns about freedom of choice

Hidden in plain sight: A systematic review of coercion and Long-Acting Reversible Contraceptive methods (LARC)

In recent years there has been extensive promotion of long-acting reversible contraceptives (LARC) globally to increase access to what is widely considered a highly effective contraceptive method. Yet, despite these efforts, evidence points towards the worrying propensity for LARCS to be associated with coercion. Hence, we undertook a meta-narrative review across nine databases to draw together the heterogeneous and complex evidence on the coercive practices associated with LARC programs. A total of 92 papers were grouped into three metanarratives: (1) law, (2) public health and medicine, and (3) the social sciences. Across disciplines, the evidence supports the conclusion that coercive practices surrounding LARC programs always target marginalized, disadvantaged and excluded population(s). Looking at coercion across disciplines reveals its many forms, and we present a continuum of coercive practices associated with LARC programming. We found that each discipline provides only a partial picture of coercion, and this fragmentation is a knowledge practice that prevents us from collecting accurate information on this subject and may contribute to the perpetuation of these suspect practices. We present this review to address longstanding silences around coercion and LARCs, and to encourage the development of clinical and programmatic guidance to actively safeguard against coercion and uphold reproductive rights and justice.

Contraception, punishment and women who use drugs

BACKGROUND

In light of the recent debate on the use of financial incentives to promote long-acting contraception and sterilisation among women who use illicit drugs we discuss attitudes to contraception, pregnancy and parenting among Australian women who inject drugs.

METHODS

Qualitative interviews were conducted with 90 women of reproductive age about contraceptive use, preferences, reproductive histories, attitudes to and experiences of parenting. All women were either currently, or had previously injected drugs. The in-depth, semi-structured interviews were compared and contrasted for themes relating to drug use, contraception, pregnancy and parenting.

RESULTS

Participants aspired to control their fertility, expressed individual contraceptive preferences and concerns for their children (both born and unborn). Most had tried a number of contraceptive methods interspersed by periods of non-use related to experiences of side-effects, being single or abstinent, believing that they were infertile and trying to conceive. Attitudes varied from woman to woman and in the same individual over their life course. Some believed that they were not likely to be capable, but most aspired to be successful mothers.

CONCLUSIONS

Women's drug use should not automatically be associated with an inability to make informed health care choices or to care for children. Evidence suggests that women who use drugs do not need to be paid to limit or end their fertility. Rather, programs that aim to reduce barriers to obtaining free, non-discriminating reproductive advice and parenting assistance would better utilise women's agency to improve their own reproductive health.

Context of care and contraceptive method use

OBJECTIVES

We assessed the relationship between context of care (incorporates insurance status with clinical setting) on contraceptive use among a national sample of reproductive-aged women. Our hypothesis is that compared to privately insured women who receive their health care in private doctors' offices, women who are publicly insured or self-pay and/or receive their health care in a clinic are more likely to use permanent or long-acting contraceptive methods.

METHODS

The study population, consisting of 4,358 women surveyed as part of the 1995 National Survey of Family Growth (NSFG) who were both at risk of unintended pregnancy and currently sexually active, was analyzed using polytomous logistic regression.

RESULTS

Following adjustment for age, race/ethnicity, marital status, education, income, parity and smoking, there was a trend toward long-acting contraceptive use among women with public insurance or who were self-pay, regardless of clinical setting compared to privately insured women seen in private clinics. Self-pay and publicly insured women of low parity tended to use long-acting contraception, as did privately insured women seen in clinics.

CONCLUSIONS

Insurance information, as well as clinical setting, may guide clinicians' contraceptive decision-making.

Racial differences in Norplant use in the United States

The introduction of the contraceptive implant Norplant has focused attention on how social factors may affect contraceptive use. In the United States, race is a central category of social organization which may impact Norplant use. I use data from the 1995 National Survey of Family Growth to answer three main questions. (1) Are women of color more likely to use Norplant? (2) To what extent can racial differences in Norplant use be explained by a structural bias in the provision of medical care? (3) To what extent can racial differences in Norplant use be explained by life circumstances which may affect individual women's contraceptive decisions? I find that African American and Native American women are more likely than white or Asian American women to be recent Norplant users. There are no differences in recent use by Hispanic origin. Both a structural bias in the provision of care and differences in life circumstances account for the disparity in Norplant use between African Americans and whites. However, none of the factors examined here explain Native American women's high rate of use. Concerns about health risks for Norplant use are also discussed. These findings point out the importance of examining structural, individual and health status factors in studies of the use of health services.

Levonorgestrel subdermal implants. Contraception on trial

When they were introduced to the world market in the 1980s, levonorgestrel subdermal implants offered the promise of an exciting alternative to traditional hormonal contraception. They provide highly effective, long-acting protection from pregnancy, without the need for user compliance. Broad acceptability of the drug has been reported throughout the world. Recently, however, the implants have met with opposition. The drug is associated with a variety of adverse effects, and removal of implants can be problematic. Serious events have been reported in women using levonorgestrel subdermal implants, although causal relationships have not been demonstrated. Additionally, concerns have been raised over the potential for coercive use of the drug. Numerous law suits have been filed alleging serious problems with implants. As a result, the drug has received considerable negative media attention. Before the controversy over levonorgestrel subdermal implants erupted, contraceptive development had declined, resulting from limitations to profits and funding, legal threats, and changes in the insurance industry. The levonorgestrel subdermal implant experience may serve to accelerate this trend. While the introduction of levonorgestrel subdermal implants offered an alternative to the current array of medical contraception, its experience may serve to dampen future contraceptive development efforts. Costly litigation and much controversy involving the implants have acted to create disincentives to further research and development of new methods of medical contraception.