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Maryland, my (current) state! Maryland's IUD/LARC push (assuming we are referring to the same thing) is particularly troubling because of the way it was carried out - but is also a good cautionary tale. Maryland's LARC push was part of an HHS grant program that funds home visitors to low income/vulnerable women during the prenatal and postpartum period. TL;DR lengthening interbirth intervals was one of the grants' goals and states had to choose their own metric. Maryland was the only state to choose LARC usage as their metric - some states measured the use of contraception generally, others measured whether or not women gave birth within a certain interval after their previous birth (usually ~12 months), and some states (such as Connecticut) chose to measure whether women were provided information about the risks of short interbirth interval. Personally, that last one is my preferred approach. What particularly concerned me about MD's program was that 1) it was targeted towards low income women, often on Medicaid 2) LARCs generally require medical assistance to discontinue 3) home visitors were advocating for these devices in mothers' homes - a particularly vulnerable area. (end tl;dr) I've done some data deep dives on this grant program more broadly and it's quite interesting - for example, HHS wants programs to be evidence-based, and privileges grant money going towards interventions that have been studied, but the most effective programs tend to be ones where the home visitor is a nurse Paraprofessional home visitors were no more effective than the control group in many studies, but many states turn to them because they are more cost effective. I imagine there are all sorts of difficulties with doing reliable studies in this area, but that facet stood out to me. I have links and articles buried on my hard drive if anyone wants to know about their state program and chosen metrics.

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Ooof, thank you so much for those extra details. It matters so much how people choose their metrics and if you pick LARCs administered, you don't know much about whether people were happy with the choice. (Plus, it enforces a much longer pause than ~12 months, especially since, as you point out, you have to see a doctor again to change your mind instead of discontinuing the pill or ceasing to use condoms).

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Yes, thanks very much for this info. I also had concerns when I heard about it. I think Delaware may have had a similar approach? There was also a push in support for promoting LARCs after Colorado reported a reduction in teen pregnancy they attributed to this (it may be part of it, but teen pregnancy rates are down across the board).

When you remove human error, you remove the error and the human--that is, human freedom to change one's mind. Women can't just remove IUDs or implants on their own. But it's very logical from a programmatic perspective. The goal is for poor women to have more space between pregnancies; contraception prevents pregnancy. Therefore, they try to increase contraceptive use (something much easier to measure than "knowledge of maternal health"). But contraceptives have something like a 7% failure rate with typical use, so that isn't a perfect solution. The program therefore benefits from removing human error; LARCs are a natural fit, because IUDs are inserted and that's it. A woman *can't* remove it on her own. So we remove the error--and the human (specifically, human freedom).

But the problem isn't just because the LARC can't be removed by the woman (although that exacerbates it). The problem is in making the personal choices of poor women the subject of a government target (a goal contraceptive prevalence rate). That creates an inherent tension between what those women want and what the state wants... super high risk of paternalism. I've also heard from an obstetric nurse in a hospital that had a lot of poor women as patients--she was unhappy to witness doctors basically pushing contraceptive shots, IUDs, etc., on these women who were probably exhausted (which relates to Kathryn's comment as well). It's worth noting that we do have reports of questionable consent sterilizations of incarcerated women giving birth in the U.S. Also, TONS of international aid focuses on contraceptive use, typically with a focus of increasing contraceptive prevalence rates. Are these all done with fully informed consent? I have my doubts.

CT's approach with options seems like the best one to me--as long as it includes all options, and is focused on health and empowering with knowledge (the risks of pregnancies in quick sequence), as long as it provides a wide range of options that respect women's values, health concerns, etc.--women need to be able to make an informed choice.

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I checked and as part of the HHS MIECHV grant, Delaware chose to measure how many women had a subsequent pregnancy within 12 months - but of course, they could have another program dedicated to pushing LARCs outside of this grant. A positive-ish indication I saw was that a plurality of states and territories (25/56) chose to measure "provision of information." This strikes me as less inherently paternalistic than measuring contraception use (15/26) or pregnancy spacing (14/26).

For me, this goes to the heart of what I want an "other feminism" for - it seems like from government programs to education to career to general cultural messaging and even in some religious contexts, only one vision of a good life is put forward: delayed marriage and childbearing, fewer children, and successfully climbing the corporate ladder. Added to that is the fact that I don't believe we can build a just society where murder is legal. There seem to be a lot of programs and research dedicated to empowering me to contribute to GDP, and not so much to enabling thick communities and enriching family life. This is particularly stark in matters of poverty - we have all of these programs dedicated to getting poor women to use contraception, but don't hold up a fundamental right to food and shelter. "Well, we still have poverty, but it's okay because impoverished women aren't getting pregnant" is not, in my opinion, actually a great outcome, but it's the impression I come away with from reading through materials on poverty and motherhood.

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