Abortion – Population Matters-USA

Advocate for LARC (Long Acting Reversible Contraception)

This is a picture of an IUD in a mockup of a uterus.

The potential of LARCs (Long Acting Reversible Contraception) is so great that I am advocating that all voters advocate for them to be paid for by government. The savings–both financial and in terms of human potential–are enormous!

Your doctor tells you that she can prescribe either of two treatments, but that one is 20 times as likely to fail as the other. Which would you choose?

Over a quarter of women in the USA use birth control pills, which fail much more frequently than Long Acting Reversible Contraception. LARCs, as they are nicknamed, are amazingly effective yet not used as frequently as one might hope.

IUDs (Intrauterine Devices) are the most commonly used LARCs. There are four available now; they are all made out of flexible plastic in the shape of a “T”. Three emit a tiny amount of hormone into the woman’s uterus, where it is most effective. The fourth IUD uses copper to gain effectiveness. IUDs are usually well tolerated, although sometimes they can increase cramps or change menstrual flow. The best medical knowledge is that IUDs do not work by aborting pregnancies.

IUDs can stay in place for a maximum of 3 to 10 years, depending on which type. Since there is a string attached, they are usually easy to remove. The string also allows the woman to check that it is in the correct place. The pregnancy rate is vanishingly small—only a couple of LARC users in 1,000 will conceive each year. This statistic for “the pill” is much higher—almost 50 per thousand will experience an unplanned pregnancy. Apparently the high failure rate of oral contraceptives in the USA is due to noncompliance. In Europe the failure rate is significantly lower; European women take their birth control pills more regularly.

There are two major drawbacks to both IUDs and the implant: they are expensive and they need to be placed by an experienced clinician. IUDs have a further drawback—bad press.

It used to be that only women with health insurance or a plump checking account could afford LARCs, but that is changing. Thanks to the Affordable Care Act (“Obamacare”), any woman with insurance, including Medicaid, can get her chosen birth control without copay. In addition, one IUD, Liletta^®, is priced much lower than the others. Here in Colorado there is a program that provides contraception, including LARCs, at little or no cost.

Placing an IUD is not difficult for a trained practitioner. The opening of a woman’s cervix may be tight is she hasn’t borne a child, but a little local anesthesia and gentle dilatation will help with the insertion.

The other type of LARC is the implant, Nexplanon^®, which is as effective as an IUD. It is a thin plastic rod that is inserted under the skin of the woman’s arm, where it can stay for up to 3 years. It emits a hormone that is very effective in preventing pregnancy. Although it is in a very low level in the woman’s blood, it is sufficient to change menstrual patterns; most women with Nexplanon^® will have spotting or breakthrough bleeding. Perhaps this is why less than 1% of women in the USA choose an implant, whereas about 6% use an IUD.

Unfortunately, reproductive health has become a political football. Here in Colorado a grant demonstrated that access to LARCs can give young women a better chance in life by decreasing teen pregnancies. By taking away the consideration of expense, the use of LARCs expanded 4 fold. Nevertheless, the false fear that IUDs might abort pregnancies kept our legislators from continuing funding to provide this effective contraception. The best way to prevent abortions is with effective birth control!

Ohio took a tip from Colorado with a program to provide LARCs. Part of that state’s motivation is to lower their infant mortality rate. They are targeting young teens and women who have just had a child, since these two groups are at high risk of having an infant die if they were to get pregnant. They also note that the state saves almost $6 for every dollar invested in LARCs.

Ohio has been proactive in another way. Some healthcare providers have misconceptions about IUDs. They think that they should only be used if a woman already has delivered a baby, or that an IUD makes a woman more susceptible to sexually transmitted infections, or teens shouldn’t use IUDs, or that IUDs can lead to sterility. All of these perceptions are wrong! Indeed, almost every woman can safely use an IUD, and start her family as soon as it is removed.

Safe, effective contraception is an important step in empowering women. We should advocate for making LARCs available to all women!

Remember how Abortion Used to Be

I returned to our room in the cheap hotel in Paris to find a bloody mess. My roommate, John, left a note that he had gone to the hospital with his girlfriend.
We were in college and were spending the summer studying the French language. John had met Ruth in London, our first stop. She was already pregnant and had decided, although it wasn’t legal, to abort the pregnancy. She arrived in Paris several days later and thought that everything had gone well. Immediately after she got to our room she started to hemorrhage. John called an ambulance, she was hospitalized, transfused and had a D&C. She recovered eventually.
That was my first introduction, as an innocent 20 year-old, to the subject of abortion, and my first brush with gynecology. It made a lasting impression.
Two years later my fiancée (and later, wife) was in graduate school and I in medical school in a different city. One of Gail’s roommates had been out of town, then spent a night in the hospital. After she returned to the apartment the police came for an official and frightening visit. The hospital reported that Jane had had an abortion and the visit was to find the identity of the doctor who had performed it. The officials interrogated her at length but left without that information.
Fast forward to when I was in general practice in New Mexico. The records of a new patient showed that she had had a hysterectomy—not unusual for a middle-aged woman. But what was surprising was the pathology report. In addition to the expected uterus, it showed a 6-inch long splinter of wood! I asked the woman how the splinter got there. She replied that she didn’t know, that she was as mystified as me. We both knew what the real story was.
During my residency I was called to the emergency room one evening to see a woman who was pregnant and bleeding. This was her 4th pregnancy; she had 3 young children at home. I thought she could be having a miscarriage. Spotting could also be an indication that the woman was trying to cause an abortion by introducing something into her uterus. Abortion was already legal in all states in the USA, although the Supreme Court decision was less than a year old.
Back then I used to warn all women with a threatened miscarriage that it was important to tell me if they had done anything to abort the pregnancy. This was because nonmedical abortions were still common, and because of the risk of a serious infection. This woman responded “no”, she would never do that—she was a member of a religion that didn’t believe in abortion.
I was surprised a few hours later when the same woman returned to the ER. She told me that she returned because what I had told her worried her. She couldn’t be sick because her children needed her. She admitted that she had, indeed, tried to cause an abortion with a knitting needle.
These are cases that I can remember well of women who faced unwanted pregnancies. All of these cases are long past history, thank goodness, because now safe abortion services are available. Regrettably some people are trying to take away access to safe, empathetic and legal abortion. Worldwide over 20 million women have unsafe abortions, resulting in 50,000 maternal deaths and many more serious injuries. “Not Yet Rain” is a video made in Ethiopia about the difficulty young women have in getting safe abortions after rape. Studies show that abortion is actually more common where it is illegal!
An unplanned, unwanted pregnancy is a difficult situation for a woman to face. Sometimes things work out well and the child is adopted. Sometimes the child is raised by the mother and loved despite an inauspicious beginning. But often things don’t work out well. Currently women in the USA occasionally resort to unsafe abortions because of increased difficulty in accessing safe abortion services.
Some politicians are trying to overthrow the Supreme Court’s Roe v. Wade ruling. They put hurdles in the way of women to decrease access to abortions. They also decrease access to contraception, the best way to decrease the need for abortion, by defunding Planned Parenthood. They advocate needless requirements for clinics that have provided safe abortion services for years without them. For women’s sake and for the sake of our already overcrowded planet we must maintain access to safe, legal abortion services.
© Richard Grossman MD, 2016