How Reversible are LARCs?
Dealing with doctors who refuse to remove IUDs
IUDs and other long-acting reversible contraceptives (LARCs) are often recommended for women who are poor, vulnerable, or otherwise going to have a hard time getting a pill prescription filled. For a long time, I’ve wondered about how easy it is for women in these circumstances to get an IUD removed.
If you use condoms for contraception, you can stop contracepting any night. If you use a shot, you have to wait until it wears off, no changing your mind in the middle. If you use the pill, you can stop taking it, and… an unpredictable amount of time later, you might conceive.
But an IUD means a trip to the doctor, which is a much bigger barrier for women without health insurance, without a relationship with a doctor, without trust in the medical system. I got to do a deep dive on this for the Institute for Family Studies here.
Over a six-month period immediately following IUD insertion, seven to 15% of women surveyed in a study tracking patients in four states considered discontinuing their IUD use. Of the 45 women in the study who considered getting their IUDs removed but did not ultimately desist, 14 women said they were unable to get their IUD removed because they could not get an appointment or because their doctor actively discouraged them when they did come into the clinic.
A qualitative study interviewed family medicine practitioners in the Bronx about their reactions to patients who sought early removal of their IUDs. Many of the doctors interviewed said they tried to steer patients to IUDs, which are more effective at preventing pregnancy than oral contraceptives or barrier methods. The researchers found that the doctors were often reluctant to accede to patient requests. “It’s a negotiation,” said one doctor, who urges patients to try to stick it out a few more months.
Some doctors were dismissive of patient concerns about bleeding and discomfort. One doctor told the researchers, “I think [the symptoms are] more annoying than anything else. I don't think it's because they're worried they're bleeding out, or they're worried that something's not working.” Some providers felt a sense of personal failure if they couldn’t convince women to stick with the method that the doctor felt best suited their reproductive plans.
There were a number of studies to draw on, including some on whether a woman can pull out an IUD at home, if she can’t reach a doctor… or if the doctor she sees refuses to help her. As I wrote:
Notably, 13% of the women who were interested in attempting to remove their own IUD said that one of their reasons was that “I thought it would hurt less than if a doctor/nurse did it.” Six percent said simply, “I did not want the doctor or nurse to do it.” It may seem strange to expect that a medical procedure would be less painful when done by an amateur at home rather than in a clinical setting by professionals, but these women’s expectations may have been shaped by their experiences in getting the IUD originally. Ignoring women’s pain is woven into the IUD experience, starting with the placement of the device.
Some of the programs that worked to get LARCs to vulnerable women thought carefully about every barrier that might prevent a woman from getting a LARC she was interested in, but seemed uninterested and uncurious about what barriers would prevent her from having a child when she felt ready.
This is an area where I think it’s natural for pro-lifers and pro-choicers to be able to work together. Many family planning programs smooth the way only towards one “choice” which makes it no choice at all.
Poor and vulnerable women risk the most if they get pregnant—having a baby during a vulnerable period of your life can make it much harder to get out of poverty. But they’re also the most at risk of being told that they’ll never be able to have children responsibly. And the risk of never “graduating” to the point where you’re allowed to have the children you long for is a pretty serious risk too.
In terms of activism or service for women (this wouldn't apply to babies) that I and more prochoice people could agree on, I recently learned about a group called Support After Abortion that does exactly what the name suggests: it puts women who've had bad experiences with abortions in touch with resources to help their emotional recovery. The focus is on emotional healing/wellbeing for women who've already had a difficult experience with their reproductive decisions, and who are NOT involved in a church or another religious group that might help them resolve what they are feeling. (SAA did a recent study on this, which suggests that about a third of women who've undergone pill abortions had negative changes in their attitude towards abortion/themselves--a minority, but not a negligible one.)
In terms of my own family planning (which is in cooperation with my husband), I have had four pregnancies with various healthcare professionals, and never (mostly for geographic reasons) been able to do it with a doctor or midwife who trusts me/us to be able to make good decisions in this regard. I usually end up having to explain Marquette (the method we use) two or three times during pre-and post-natal care and turn down multiple other offers for other contraception, including the offer to have my tubes tied. On the one hand--I get why healthcare professionals keep asking: it's part of what they are supposed to do, like checking weight and taking blood pressure. Also, we have four kids who are close in age! But on the other hand, it gets tiring to explain the method, explain that no, none of these children were mistakes, explain that yes, I absolutely can do this post-partum and we can handle the abstinence ... and still get met with a skeptical, incredulous, "Well, if you really think that's what you want ..." It feels a little infantilizing. But on the other hand yet again, it is the job of a healthcare professional to take care of their patients/clients. It is just very difficult to do that in a respectful way when there are some deeply shared values that aren't held in common--because the doctor and patient each think they know what is best for the patient, and the gap is not one of technical knowledge, ultimately, but of ethics.
Such a good article, Leah, and I really appreciate your attention to this issue. I know friends who have had trouble getting their IUD out for the most benign of reasons, such as that their OB's office was very busy, and there just was no appointment available for a month or two, or their OB wanted to schedule a "pre-conception counseling" visit before removing the IUD when a woman had decided to try for a pregnancy. This seems minor, but for a woman in her thirties (or really at whatever age) any wait once the decision has been made to try for a baby can be really hard.