Contraception Family Planning Population Reproductive Health

Sometimes it is Best to Hide Contraceptive Use

            55 years ago a young patient and I were standing in the sun just outside the clinic doorway when a butterfly alighted on my left ear. “Yes, I would like to try an IUD” the patient said, amazed and apparently encouraged by the butterfly.

            It was the summer between my 3rd and 4th years of medical school. My new wife and I were having a wonderful adventure at the Moravian Hospital in Puerto Cabezas, Nicaragua.  The patient I had been persuading to try an IUD was also newly married and wanted something to keep from conceiving right away. She didn’t think her husband would approve of using birth control, however.

            “If you had an IUD, he wouldn’t know about it unless you told him,” I had encouraged her. Apparently, the butterfly landing on my ear was the deciding factor, and I was able to insert a Lippes loop.

            Hiding contraceptive use is a common strategy in many countries where patriarchy rules. Men in patriarchal societies usually desire large families, and don’t want their partners to make decisions about childbearing. Research has found that covert use of contraception is common in some African countries, especially for wives of polygamous marriages. As many as a third of women in some places conceal their use of birth control! Although I am certain that some women in the USA use contraception without their partner’s knowledge, I have not been able to find a study of its prevalence in this country.

Some birth control methods are easier to hide than others. A pack of pills would be easy to conceal, but it would be a dead giveaway if found. DepoProvera® shots are effective for 3 months and are easy to keep secret. A wife could go into town to shop, as usual, but also stop at the health clinic for her birth control shot. Indeed, some women have stated that is one of the reasons they chose thei method. 

            There is a new form of DepoProvera® that is packaged so that a woman can give it to herself at home. It is small enough that the pre-filled injection unit would be easy to conceal. Large studies in African countries have found women like this formulation, but unfortunately Sayana®Press is not available yet in the USA. There are other LARCs (Long-Acting Reversible Contraception): Nexplanon®, good for 3 years, and several IUDs, which last up to 10 years, are all easily concealed.

            I do not recommend covert use of contraception. However, in some cases it is the only way that women can avoid unwanted pregnancies. Since the majority of family planning methods are female-controlled, the wife should—and can (by hiding her birth control)—have the last word about childbearing.

It only seems right that women should decide about family planning since birthing and most of the responsibilities for childcare rest on women’s shoulders. However, it is best if husbands and wives talk about whether to use contraception, and together choose the method that would be best. This is supported by a statement of friend, Dr. Stan Becker, who has studied reproductive health decisions among couples: “…reproductive health interventions that target couples are found to be more effective than those directed to only one sex.” 

           However, we don’t live in a perfect world—unfortunately, there are many couples where power and decision-making are not shared. Since family planning is recognized as potential driver of women’s autonomy and health, covert use of family planning can be seen as a symbol of agency for the women in these relationships.

© Richard Grossman MD, 2024

Family Planning Reproductive Health Sterilization

The Other Side of Reproductive Coercion

The image above provides information about the article cited below.

            Reproductive health abuses, especially coercion, have turned many people away from concern about human population. I agree: reproductive coercion should be shunned.

            Examples of coercive actions include sterilization of both women and men in India—even though patients didn’t really know what was being done. Coerced sterilizations also happened in the early 20th century in the USA—especially people who were who weren’t of the dominant race or were thought to be mentally or genetically deficient.

            There were attempts to wipe out Native Americans, which started when Columbus “discovered” the New World, and may have continued into the 20th century. This apparently happened at Indian Health Service hospitals, where a high proportion of Native women had their tubes tied. Fortunately, federal laws now require use of a special consent form that makes it difficult to perform sterilization procedure without real informed consent.

I have also read about Puerto Rican women being sterilized against their will in the past. When I practiced there in the 1980s, I saw no sign of coercive sterilization. In fact, the reverse was true. I remember Maria, who was desperate to stop having children. She couldn’t afford reliable birth control such as an IUD and pleaded with me to tie her tubes. Unfortunately, she didn’t have insurance and the hospital wouldn’t let me do the surgery unless they could be certain of payment.

 That brings up the other side of reproductive coercion—women are often forced to bear, and raise, children that they did not intend to have.

Obamacare and many other programs will pay for contraception in the US. However, most governmental programs will not pay for an abortion when a contraceptive method fails. Unfortunately, unintended pregnancies occur with all methods, and some states prohibit abortion under any circumstance, including rape.

 Since abortion has been tightly restricted or outlawed in many states, it has become impractical for countless women to obtain abortion care. Unfriendly laws have coerced many women to carry unintended pregnancies. Although networks exist to help women abort unwanted pregnancies, many people still aren’t able to make the choice they want.

A careful study of births in Texas found that abortion-limiting legislation increased unintended births. This research compared the number of births after Texas Senate Bill 8 (preventing abortions after 7 weeks of pregnancy) was in effect with the prior years’ births. They found that there were almost 10,000 more births in the relevant 9 months after SB8 took effect. Many of these excess births were probably unwanted because the women were coerced into carrying a pregnancy by their inability to access abortion care.

I predict that coercing women to bear and raise children will have bad effects on society. We know that people who result from unwanted pregnancies don’t do as well in life; they have more contact with mental health and with law enforcement agencies. We also know that Texas has one of the higher maternal mortality rates in our country, and forcing women to give birth is likely to cause the death rate to go even higher.I believe that the basis for antiabortion laws has little to do with the claimed religious beliefs; the states with the strongest “right to life” laws seem to have the weakest support of mothers and children after birth. I also believe that many people who advocate against abortion and for population growth do so for selfish economic reasons. Speaking of population growth, Nandita Bajaj, an expert on a cause of population growth—pronatalism—will be talking at Lifelong Learning in Durango on February 15th

© Richard Grossman MD, 2023