The Comeback of the IUD in Twenty-First Century USA

Abstract

From 1995 to 2014, intrauterine devices (IUDs) rose from ranking 10^th (out of 11) among contraceptive methods to being the fourth most popular, outnumbered only by the pill, sterilization, and condoms. In 1995, the IUD had been largely abandoned by American doctors; two decades later, major medical associations promoted it as a “first line” method for prospective users of all ages. This paper explains the rapid and dramatic increase in intrauterine contraception by exploring three influential factors from the 1970s-1980s – the Dalkon Shield disaster, the lack of innovation in contraceptive research and development, and the moral panic over teen pregnancy in America – that created circumstances by the early 2000s in which health care providers became more receptive to long-acting reversible contraception. Key thought leaders in obstetrics and gynecology took it upon themselves to rehabilitate the IUD in the court of medical opinion and succeeded in securing professional approval of the device as the initial step in its resurrection.

In 1995, intrauterine devices (IUDs) were used by just over 300,000 American women, or less than 1% of the total using some form of contraception. In 2014, IUDs were used by four and a half million, or almost 12%. In under twenty years, the IUD rose from ranking 10^th (out of 11) among birth control methods to being the 4^th most popular, outnumbered only by the pill, female sterilization, and the male condom. In 1995, the IUD had been largely abandoned by American doctors; twenty years later, major medical associations promoted it as a “first line” contraceptive for prospective users of all ages. What accounts for this rapid and dramatic increase in intrauterine contraception, from forgotten to favored?

To answer this question, we need to look back to conditions developed during the 1970s and 1980s. There we find the origin and continued influence of three factors key to the recent history of the IUD. The first was the demise of the Dalkon Shield IUD, which caused several deaths and many more injuries to women in the early 1970s. Although the Dalkon Shield was taken off the American market in 1974, hundreds of thousands of women continued to wear it into the 1980s, when revelations of bad actions taken by its manufacturer, A. H. Robins, came to light. The unscrupulous marketing of this flawed device tainted medical and popular impressions of all intrauterine devices, and from 1986 to 1988, none was available to women in the United States. Second, and coincident with the decline of the IUD came consternation about the lack of innovation in contraception. American pharmaceutical companies had all but abandoned research and development into new birth control methods. In 1970, nine U.S. firms were actively engaged in contraceptive R&D; by 1987, that number had shrunk to one.

The third significant element was heightening concern about teen pregnancy in America. Teen pregnancy was described as an epidemic starting in the late 1970s, and as media coverage grew in the next decade, the rhetoric intensified. In the 1990s, attention shifted to focus on single mothers of all ages, not just teenagers, and politicians, policy makers, and journalists speculated about the role of welfare in contributing to this alleged problem, which was portrayed as both a social and a public health issue.

By the early 2000s, these developments had created circumstances in which health care providers became more receptive to the notion of long-acting reversible contraception (LARC) in the form of the IUD. The group that had to be first to buy back in to the IUD was the medical profession, because IUDs (and implants, the other LARC method) must be inserted by health care providers. Some key thought leaders in obstetrics and gynecology took it upon themselves to rehabilitate the IUD in the court of medical opinion. This process of exculpation and reinstatement returned the IUD to the forefront of American discourse about birth control.

This article extends the historical analysis of reproductive politics into the twenty-first century by building on the rich historiography of contraceptive technology in the United States.¹ It continues my own journey as a historian of birth control, from my initial work on the pill to later investigations of Norplant. While the Dalkon Shield was the subject of several volumes published in the 1980s and 1990s, the most recent book on the IUD is Chikako Takeshita’s The Global Biopolitics of the IUD: How Science Constructs Contraceptive Users and Women’s Bodies. Here I expand upon Takeshita’s excellent work by extending the narrative into the late 2010s and complementing her science studies approach with a historical analysis of physicians’ roles in effecting the recent transformation in contraceptive attitudes and practices. I have used a variety of sources – published reports, medical journal articles, professional society directives, popular literature, the records of the National Academies of Sciences, the records of the National Women’s Health Network, and oral history interviews – in interrogating the historical record to understand how the IUD made its comeback. While women’s knowledge of, opinions about, and attitudes toward the IUD were essential to the timing and pacing of its resurrection, this essay focuses on professional approval of the device as the initial step.

The Rise and Fall of the Dalkon Shield

It is no secret that Margaret Sanger, the mother of the birth control movement in the United States, was a proponent of negative eugenics and believed that “unfit” people should not reproduce.² Although eugenics fell out of favor toward the end of the 1930s, a new generation of demographers in the mid-twentieth century (many with ties to the pre-war eugenics movement) stirred up alarm about population growth in the global South, using statistical modeling as a purportedly “objective” method of analysis to attribute the rapid rise to women’s unrestrained fertility.³ The gender bias of these Western demographers, combined with their simplistic, Cold War era conviction that overpopulation would lead to political instability and the “fall” of developing nations to Communism, drove them to search for an alternative to the oral contraceptive for use in these countries. More specifically, they sought a long-acting contraceptive that could be placed – literally – beyond a woman’s direct control.

In the late 1950s and early 1960s, they revisited the ancient method of intrauterine contraception, making devices out of plastic instead of the silkworm gut or silver used in the early twentieth century. Their goal was to provide inexpensive, long-lasting birth control on a large scale to bring down fertility rates in Africa, Asia, and South America. The modern IUD fit the bill; in the words of the president of Planned Parenthood, “No contraceptive could be cheaper, and also, once the damn thing is in the patient cannot change her mind.”⁴

IUDs rose in popularity in the United States in the early 1970s, after the safety of oral contraceptives was called into question. By 1973, almost 10 percent of women who used contraception wore an IUD, and most of them wore a newly-released device called the Dalkon Shield. Developed by Johns Hopkins University physician Hugh Davis and marketed by the A. H. Robins Company, Science News magazine spotlighted the Dalkon Shield on the cover of its 8 August 1970 issue as the “second generation IUD.” Within just a few years, A. H. Robins sold 2.86 million of the devices in the United States (2.2 million inserted) and another 1.71 million abroad (1 million inserted).⁵

The story of the downfall of the Dalkon Shield has been told in dozens of articles and books, most notably by the Washington Post investigative journalist Morton Mintz in a newspaper series that became a book in 1985 called At Any Cost: Corporate Greed, Women, and the Dalkon Shield. The device caused at least eighteen deaths in the United States alone and tens of thousands of serious infections, because the multifilament string that hung into the cervix wicked bacteria from the vagina into the uterus. The Dalkon Shield was also almost five times less effective than advertised. Some 110,000 women (one out of 20) became pregnant with the device in place, 60 percent of whom miscarried.⁶

In June of 1974, A. H. Robins suspended sales of the Dalkon Shield in the United States; fourteen months later, the company took the device off the market. However, neither Robins nor the FDA advised physicians or women to remove the device until September 1980, so hundreds of thousands continued to wear the Dalkon Shield into the 1980s. It took four more years for A. H. Robins to set up a program to advertise and pay for the removal of all remaining devices. By the time the company filed for bankruptcy in 1985, it had faced more than 14,000 lawsuits.

Women’s magazines were quick to question the safety of IUDs. In the October 1973 issue of Good Housekeeping – even before the bad news broke about the Dalkon Shield – there was an article titled, “Are IUD contraceptives safe?”⁷ In January 1975, another article asked, “IUDs: Are they really safe?”⁸ In the March 1976 of Redbook, an author vividly recalled the miscarriage brought about by her IUD.⁹ In July 1978, Good Housekeeping published a similar first-person IUD horror story, in which the author described getting pregnant after a few months with an IUD and then suffering a perforated uterus seven years later.¹⁰ But that fall, Good Housekeeping’s article about new warnings from the FDA on the risk of pelvic inflammatory disease for IUD users reassured readers, “It’s still a safe method of birth control … Still safer than the Pill.”¹¹

A 1978 survey asked American gynecologists about the birth control methods they recommended to patients. Of the 3000 surveys sent out, 1350 (45%) were returned. Although the gender of the respondents was not identified, we can presume that most were male, since women made up just 10% of the physician workforce at the time.¹² There was not much difference between recommendations for the pill (46%), the diaphragm (43%), and the IUD (40%).¹³ These figures were at odds with a survey that had queried female doctors three years earlier. While 66% of this group recommended the pill, just 8% recommended the IUD and 7% the diaphragm. These recommendations did not square with their personal birth control choices: 33% used oral contraceptives, 25% used IUDs, and 20% used diaphragms.¹⁴ And this pattern of use also contrasted with that of 800 Planned Parenthood staff and volunteers queried in 1979: 8.8% said they were pill users, 38% had a diaphragm, and 13% had an IUD.¹⁵

Through the 1970s, the nation’s premier organization of doctors concerned with women’s health, the American College of Obstetricians and Gynecologists (ACOG), attested to the value of including IUDs in the birth control armamentarium. Its very first technical bulletin on intrauterine devices, published in September 1968, recommended that “skill in its use should be acquired by every obstetrician-gynecologist.”¹⁶ A revised version published in September 1974 summarized the opinion of the College’s Advisory Committee to the Division of Family Planning: “The IUD is a safe and effective method of contraception … The IUD is an ideal method of contraception for patients who do not tolerate hormonal contraception or have difficulty remembering to utilize other methods of contraception.” It made no mention of the Dalkon Shield.¹⁷ Less than two years later, a third revision of the technical bulletin included the advisory that “Patients with the Dalkon Shield should be advised of the hazards of the multifilamented tail, and the use of other methods encouraged,” but still affirmed – in the very first sentence – “The IUD is a safe and effective method of contraception.”¹⁸

Data from Planned Parenthood showed a decline in the percentage of patients choosing IUDs, from 15.3% in 1970, to 10.0% in 1973, to 4.5% in 1980.¹⁹ Although fewer women chose to have new IUDs inserted, women who already had IUDs apparently chose to keep them. The 1982 National Survey of Family Growth showed “a small but nonsignificant decline in IUD use between 1973 and 1982” among currently married women from 9.6% to 7.1%.²⁰ The decline became significant over the next decade. In 1988, just 2% of American women had an IUD, as the total number of users plummeted from 2.2 million to 0.7 million.²¹ Those figures continued to shrink into the 1990s, bottoming out at 310,000 (0.8%) in 1995.²²

Certainly, the widespread media coverage of the legal battles of A.H. Robins in the 1980s and eventual declaration of bankruptcy in 1985 contributed to the decline in trust of IUDs among both doctors and women, but it was not just the Dalkon Shield that triggered this reaction. G. D. Searle’s Copper-7 (which began sales in 1974 just as Dalkon Shield sales were being suspended) quickly became the most popular IUD model in the United States, but it also racked up concerns and complaints over its safety, leading to hundreds of lawsuits by the mid-1980s. In 1986, Searle threw in the towel and withdrew both the Copper-7 and the Tatum-T (another copper-containing IUD approved in 1979) from the American market.²³ In 1982, Julius Schmid Laboratories had ceased production of the Saf-T-Coil (introduced in 1967), and in 1985, Ortho Pharmaceuticals had stopped selling the Lippes Loop (introduced in 1962). Both IUDs had suffered declining sales in comparison to the newer copper-containing devices.²⁴ Searle’s exit from the market meant that American women had no access to IUDs that could be left in place for several years. (The Alza Corporation’s Progestasert, a hormone-releasing device, was in limited distribution and had to be replaced every year. It accounted for just 3% of IUD sales in 1984.)

In 1987, ACOG replaced the 1976 technical bulletin on the IUD with a considerably more reserved version. It began by acknowledging that the removal of all multi-year models from the market left American doctors with two issues: first, what to do about patients still wearing IUDs, and second, what to do with IUDs already purchased and sitting in boxes on the shelves of their offices? Doctors were advised not to remove a device until the normal replacement time, unless the woman was experiencing complications, and to return the unused devices to the manufacturer.²⁵ The technical bulletin dutifully went on to describe uses and contraindications, techniques of insertion, and potential complications, even though it was unlikely that many patients would be requesting new IUDs (and even if they did, the only one available was the one-year Progestasert).

The Stalled Contraceptive Revolution

In 1988, the majority of women trying to prevent pregnancy in the United States primarily used one of three methods: the pill (30.7%), condoms (14.6%), or permanent sterilization (39.2%).²⁶ In other words, with the demise of the IUD, women were using the same kinds of birth control available to them for three decades; no new methods had been introduced to the American market. Carl Djerassi, one of the developers of oral contraception in the 1950s, had warned in a 1970 Science article that the high costs of contraceptive research and development and onerous federal regulatory processes might stymie innovation; in a follow-up piece 19 years later, he lamented that his prediction had come true.²⁷

Concern about the dearth of new contraceptives available to American women prompted the Andrew W. Mellon Foundation to sponsor a study by the National Research Council (NRC) and the Institute of Medicine (IOM) in the late 1980s; the final report, Developing New Contraceptives: Obstacles and Opportunities, was published in 1990.²⁸ The report began by making a persuasive case for the need for new contraceptives: to reduce the number of abortions and to allow for child spacing that would improve the health of both women and children. The study committee, a distinguished group of physicians, professors, and other professionals, observed that people needed different kinds of contraceptives at different stages of their lives; this was reason enough for an expansion in the variety of methods. After reviewing the current status of contraceptive research, the report condemned the paucity of funding from government, non-profit, and private sector sources. It concurred with Djerassi’s assessment of the onerous obstacles presented by the FDA and called for modifications for contraceptive products. As Djerassi had done in his 1989 article, the committee focused on the threat posed by product liability and the increasing amount of litigation over contraceptive drugs and devices (including, but not limited to, the Dalkon Shield and other IUDs). The report concluded with a call for changes to product liability rules to encourage new product development by America’s pharmaceutical industry.

The media picked up on the NRC/IOM report. Time revealed the “dirty little secret about the birth-control ‘revolution’,” namely, that American birth control was in a “dismal state,” with six million unintended pregnancies each year. Both Time and US News & World Report quoted Carl Djerassi, who said that “the United States is the only country other than Iran in which the birth-control clock has been set backward.” Glamour illustrated the deficiency in annual federal spending on contraceptive development in the 1980s ($16.6 million) by comparing it with annual federal spending on dental and oral health ($102.6 million), the cost in 1990 for the President’s own Marine band ($7.4 million), and a single Stealth bomber ($486 million). Newsweek and Time called out the fear of litigation as a prime disincentive for corporate contraceptive research and development, along with the effective tactics of the conservative right-to-life movement. Only Forbes, the business bi-weekly, identified a silver lining to the product liability crisis, at least for one company: because other drug firms had been scared away, Ortho Pharmaceuticals was left with free rein in the contraceptive marketplace.²⁹

Two new methods were approved in the early 1990s; neither, as it happened, was developed by Ortho. In 1990, Wyeth-Ayerst was licensed as the American distributor of Norplant, the five-year implant, and in 1992, Upjohn finally gained permission to market its three-month injectable that had been in development since the 1960s. Both of these methods offered new ways to get synthetic versions of the hormone progesterone into a woman’s body to prevent ovulation and, hence, pregnancy. After an initial burst of enthusiasm, neither method was adopted by more than a few percent of American women. The 1995 National Survey of Family Growth found just 1.3% of women used the implant and 3.0% used the injectable (about the same number as those who relied on the age-old unreliable method of withdrawal).³⁰

In 1993, the IOM once again took up the issue of contraceptive research and development, on the instigation of the Rockefeller Foundation’s initiative to “mobilize the resources of all sectors toward a ‘second contraceptive revolution’.”³¹ The Rockefellers had supported birth control initiatives since the 1920s, and John D. Rockefeller, III, was instrumental in the establishment of the Population Council in 1952. Four decades later, the Foundation sought to jumpstart the next generation of contraceptive innovation, fearing that available methods were inadequate to meet the range of women’s needs in different countries and different circumstances.

With support this time from five sponsors (the Andrew W. Mellon Foundation again, plus the Rockefeller Foundation, the National Institute for Child Health and Human Development, the United States Agency for International Development [US AID], and the Contraceptive Research and Development Program, a cooperative non-profit between US AID and Eastern Virginia Medical School), the IOM study committee (just two of its 17 members had served on the 1990 committee) tackled three questions: 1) was there really a need for new contraceptives, 2) were there prospects in science that could reenergize contraceptive research and development, and 3) was the science sufficient to accomplish revitalization and, if not, what else would it take in terms of climate and resources?

The answer to the first question was a definite yes. The committee deemed it unacceptable that, “by the end of the 1980s, women in the United States had one effective reversible method, the pill, and one effective permanent method, sterilization.”³² But why had not advances in cellular and molecular biology and biotechnology been applied to the realm of contraception? The resulting report, published in 1996, spent 347 pages (exclusive of appendices) examining basic and applied research opportunities and investigating ways to overcome the barriers to productive partnerships to bring new contraceptives to market.

The committee acknowledged the work of its predecessor in identifying three important obstacles: product liability laws that encouraged litigation, burdensome federal regulatory requirements, and a hostile political and ideological climate toward matters of sex and reproduction the United States. This time, however, the committee distilled the primary roadblock to one factor: economics. Without intervention, the size and scope of the potential market for new birth control methods could not provide a significant return on the investment in research and development. Put simply, pharmaceutical companies could not make money in contraceptive innovation. The report looked to the federal government and policy makers to “translate unmet need into market demand” by developing incentives and a more hospitable climate for the private sector to get involved in converting the fruits of basic research into marketable products.

The call for greater investment in basic research to provide a scientific foundation for the development of truly innovative contraceptive agents (as opposed to “me-too” formulations of existing compounds) was not new. Two decades earlier in 1976, the Allan Guttmacher Institute – then the research, policy analysis, and public education arm of Planned Parenthood – published a report demonstrating the need for a tripling of spending on reproductive and contraceptive research to develop an “adequate program to apply current knowledge.” To implement a “high priority program” would require a fivefold increase. It noted that the National Institutes of Health (NIH) spent 17 times more on cancer research and seven times more on heart and lung research; all told, research on reproduction and contraception accounted for less than two percent of the NIH annual budget. Five years later, a follow-up report drew the same conclusion: the U. S. government would need to quintuple its investment to see real results in the development of new contraceptive methods.³³

The Moral Panic Over Teenage Pregnancy

These earlier appeals for increased financial support were not part of reports on the stagnation of contraceptive research. Rather, they were included as recommendations to address the problem of teenage pregnancy. The 1976 report was called, alarmingly, 11 Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States? The 1981 report carried the bleak title, Teenage Pregnancy: The Problem That Hasn’t Gone Away.

Teenage pregnancy was brought to light as a national concern by Life magazine in a cover story on 2 April 1971.³⁴ The article featured a special program for pregnant girls and teen mothers at a public high school in California. That same year, demographers undertook the first-ever study of contraceptive use among teenagers. Published in 1973, the results indicated that 28% of the 4000 15-19-year-olds surveyed had had sex, but less than a fifth of those reported consistent contraceptive use.³⁵ For the researchers at the Allan Guttmacher Institute, the connection was obvious: improved access to birth control information and services and research into new methods were critical to the prevention of teen pregnancies.

Media reports on teen pregnancy in the 1970s picked up on the epidemic trope: McCall’s advertised its story, “The Teenage Pregnancy Epidemic,” on the cover of the July 1978 issue, and Family Health devoted its monthly House Call column, penned by “a noted medical specialist or health authority,” to “Epidemic: Teenage Pregnancy” in February 1978.³⁶ Coverage really took off in the 1980s, as concern escalated into a full-fledged moral panic. In 1980, Ebony promoted an article about “The Growing Problem of Teen-age Pregnancies” on the cover of its March issue. In March 1985, a pregnant teen was featured as the cover image for the issue’s main story, “What Must Be Done About Children Having Children,” written by Dorothy I. Height, president of the National Council of Negro Women. Two years later, Marian Wright Edelman, president of the Children’s Defense Fund, weighed in with a strongly worded agenda for “How to Prevent Teenage Pregnancy.” In 1985, reporting on yet a third study to come out of the Allan Guttmacher Institute, Newsweek begin its article on “A Teenage Pregnancy Epidemic” with a dilemma: “Unwanted teenage pregnancy is a tragedy, most Americans would agree; they differ only on which of the two likely outcomes – an illegitimate birth or an abortion – is the least palatable.”³⁷ Its 1987 cover story, “Kids and Contraceptives,” identified the prevention of teen pregnancy explicitly as a “moral dilemma” and added the complicating factor of AIDS prevention into the mix.³⁸ These articles identified a constellation of factors contributing to the uniquely American problem of high rates of teenage pregnancy (as compared to other developed nations), giving more weight to some over others depending on the editorial slant of the publication. Almost all of them featured some discussion of contraception, be it lack of access, misuse or nonuse, the ill-suitedness of some methods for adolescents, or conservative repudiation of use by unmarried teens.

The NRC lamented the lack of evidence-based knowledge and decision-making about adolescent sexuality, pregnancy, and childbearing. In 1984, with funding from five private foundations, it formed a panel to study trends in teenage sexual and fertility behavior, antecedents and consequences of teenage pregnancy and childbearing, and existing policies and programs to prevent pregnancy and to support teen parents. The resulting report, Risking the Future, was released in December 1986 and published as a book in 1987. Its findings matched those publicized by the Allan Guttmacher Institute: over a million pregnancies, resulting in 400,000 abortions and 470,000 births, mainly to unmarried mothers. Rates of pregnancy and birth were much higher than those in other developed countries, although rates of early sexual activity were similar. The panel was clear in its recommendation: “prevention of adolescent pregnancy should have the highest priority.” In spite of conservative forces advocating abstinence-only programs, the panel concluded that “making contraceptive methods available and accessible to those who are sexually active and encouraging them to diligently use these methods is the surest strategy for pregnancy prevention.”³⁹

Just six years later in 1993, the IOM took on the thorny subject of teen pregnancy (within the Division of Health Promotion and Disease Prevention, different from the committee in the Division of Health Sciences Policy that was formed the same year to investigate contraceptive research and development). For this second study, the scope was both redefined and expanded, first, by focusing on unintended pregnancy (which included pregnancies that were either unwanted or mistimed), and second, by examining unintended pregnancies among women of all ages, regardless of marital status. The panel was compelled by stark data: of 5.4 million pregnancies in 1987, 60% were unintended and resulted in 1.6 million abortions and 1.5 million births. Moreover, after decreasing during the 1970s, this percentage had increased in the 1980s. The final report, published in 1995, stated unequivocally: “Unintended pregnancy is not just a problem of teenagers or unmarried women or of poor women or minorities; it affects all segments of society.”⁴⁰ In addition to recommending improved knowledge about and access to birth control and more research to develop new contraceptive methods, the panel argued for attention to “the major roles that feelings, attitudes, and motivation play in using contraception” and the development and evaluation of programs to prevent unintended pregnancies.

In a creative move, the panel packaged its recommendations into a call for a national campaign, like those that had been organized to tackle the public health issues of smoking, drunk driving, and seat belt use. President Bill Clinton championed this idea in his 1995 State of the Union address:

We've got to ask our community leaders and all kinds of organizations to help us stop our most serious social problem: the epidemic of teen pregnancies and births where there is no marriage. I have sent to Congress a plan to target schools all over this country with anti-pregnancy programs that work. But government can only do so much. Tonight, I call on parents and leaders all across this country to join together in a national campaign against teen pregnancy to make a difference.

Clinton perpetuated the epidemic trope, which identified the problem as a public health matter and also kept up the sense of urgency. For this president, unmarried teenagers were the main demographic that made up the “most serious social problem,” ignoring the IOM committee’s recommendation for a broader scope.⁴¹

However, by the early 1990s, the moral panic about teenage pregnancy had already expanded to include pregnancies among unmarried women of all ages. An article in Mademoiselle titled, “The Great American Birth-Control Crisis,” began with the “facts”: 51 percent of pregnancies were unplanned, 30 percent ended in abortion, and 57 percent of unmarried women ages 20-29 used no birth control. “What’s going on here?” asked the author. “Why is the United States bringing up the rear in the birth-control race?”⁴² Her focus was not on middle and high schoolers, but rather on “young, educated women who balance their checkbooks, pay their bills, get regular dental checkups and hold down good jobs.” She acknowledged the complex of factors leading to unprotected sex, from cultural signals that made women feel guilty about having premarital sex to individual risk-taking behavior to the cost of birth control in America, before landing on the “outrage” of the paucity of available methods and calling for a revival of research into new contraceptives.⁴³

The national conversation took an ugly turn toward an attack on poor single mothers when policy makers and journalists connected the dots to welfare. A Time cover piece in 1994 asked about mothers on welfare: “Reform may put them to work, but will it discourage illegitimacy?”⁴⁴ Implicit in this question was unfounded speculation that pregnancies among the poor and unwed might actually be intentional for the purposes of receiving welfare payments. According to the article, “Nearly a third of American children are born out of wedlock, and those children are four times as likely as the others to be poor. Unwed mothers average nearly 8 years on welfare, in contrast to 4.8 years overall.”⁴⁵ In the early 1990s, law-makers in more than a dozen states attempted to incorporate the newly-approved contraceptive implant, Norplant, into their strategies for dealing with single motherhood and the welfare system. Although none of the bills was ever signed into law, they demonstrated the readiness of legislators to propose coercive use of long-acting provider-controlled contraception to curb the fertility of certain segments of their female constituencies.⁴⁶

Bringing Back the IUD

Long-acting contraception had advocates in other corners, many of whom were willing to look past the disturbing implications of promoting birth control methods not controlled by women themselves. In 1996, an article published in the American Journal of Public Health by policy analysts at the Hastings Center proclaimed, “Broad-brush public policies that require long-term contraceptive use are unethical. However, persuasion to use these methods can be appropriate.”⁴⁷ For decades, family planners had been persuading and, at times, pressuring women in developing nations to use long-acting methods. The abandonment of the IUD in the United States in the late twentieth century contrasted sharply with that of the rest of the world where, in 1985, IUDs were used by some 60 million women.⁴⁸ (Twenty years later, they were used by 128 million and had become the most popular form of reversible contraception worldwide.⁴⁹) While voluntary uptake accounted for a proportion of these numbers, the coercive use of IUDs, implants, and sterilization was also well-documented.⁵⁰

Multi-year IUDs were distributed across the globe by American and international organizations such as the US AID, International Planned Parenthood Federation, and the World Health Organization, but recall that, in 1986, they were no longer being sold in the United States. Family planning advocates realized that this discrepancy looked bad: how could the American government and donors from the Global North consider the IUD safe for use by women in other countries but not by women in the United States? Scholars speculate that this rationale encouraged the startup pharmaceutical company GynoPharma to begin to sell Paragard in the United States in 1988.⁵¹

This copper-releasing T-shaped device was developed by the nonprofit Population Council in the 1970s and received FDA approval in 1984. It was manufactured by Finishing Enterprises Inc., initially only for distribution outside the United States. Soon after GynoPharma began to market Paragard in 1988, the FDA extended its period of use from four years to six. The length of time was extended again in 1991, to eight years, and again in 1994, to ten years. But Paragard’s debut was not helped by the media. An ominous report published by Vogue in 1988 with the title, “The New IUD: The Enemy Within?” began, “For better or worse, a copper intrauterine device (IUD) has returned to the American market. Although some experts are hailing it as a much-needed birth control alternative, others raise serious questions about its safety.”⁵²  Prevention’s article, “IUDs Are Back,” focused on the requirement for prospective users to read and initial every section of a patient information pamphlet as a way of giving their informed consent. The article went on to warn that “the newer IUDs carry more risk of infection and sterility than other forms of birth control.”⁵³ In case readers had forgotten what had happened with the older IUDs, the author of Mademoiselle’s article reminded them: “The timing is ironic. Just as the courts have ordered one company to pay nearly $2.5 billion to women harmed by the Dalkon Shield IUD (intrauterine device), another manufacturer is launching the first IUD to come on the American market in years.”⁵⁴ Perhaps not surprisingly, given this reporting, IUD use continued to fall from 1988 to 1995, as more women had IUDs removed than inserted.

The reversal of this decline in the ensuing years may have had something to do with the availability of the Mirena IUD. Its ancestor, the first hormone-releasing IUD, was developed by a Finnish doctor, Jouni Valtteri Tapani Luukkainen. Sold in the United States as Progestasert by the Alza Corporation starting in 1976, it had to be replaced annually and never became popular. Luukkainen experimented with the use of a different synthetic progesterone, levonorgestrel (the same one used in the Norplant implant and several brands of oral contraceptives), and found that the lifespan of the IUD could be increased to five years. Leiras Oy, a Finnish drug company, introduced this new hormone-releasing device in its home country in 1990 as Levonova, and within 10 years it was being sold and used in 27 other nations. The device, re-branded as Mirena, received FDA approval in December 2000 and hit the U.S. market in 2001. The news coverage of Mirena was much more benign than the earlier reporting on Paragard. Most articles that described Mirena in the early 2000s also included the ring, the patch, and Lunelle (a one-month injectable), and celebrated “the new no-hassle birth control” that “aim to make contraception easier.”⁵⁵

Both Paragard and Mirena were initially marketed only for women who had previous births. The “para” in the Paragard tradename refers to a woman being “parous,” which means having produced offspring.⁵⁶ Although Paragard was tested in both parous and non-parous women, with no discernable differences in outcomes or side effects, GynoPharma made the indication for parous women implicit in its advertisement in medical journals, by illustrating it with a photograph of a married woman (her wedding ring is clearly visible) with her husband and two young children.⁵⁷ Berlex’s three-page advertising spread for Mirena in Obstetrics & Gynecology showed a woman and a man frolicking on the beach with their two children. The prescribing information included in the ad clearly stated, “Mirena is recommended for women who have had at least one child.”⁵⁸ IUD use rose in the United States between 1995 and 2002, according to the National Survey of Family Growth, accounting for 2.0 percent of contraceptive use (up from 0.8 percent). Women between the ages of 25 and 39 were the biggest users, as were women who had two children. Although both the absolute number of IUD users and the relative number as compared to other methods still remained very small, the percentage of users more than doubled in seven years.⁵⁹ And this figure would increase another six-fold over the next 12 years.

Spreading the Gospel of LARC

The story of the IUD’s remarkable comeback begins in New Mexico, where a newly-minted obstetrician-gynecologist named Eve Espey was starting her career in the early 1990s.⁶⁰ Working as a staff physician for the Indian Health Service, she was dismayed by the paucity of birth control options available to girls at the teen clinic she ran in Gallup, and she saw that pregnancy dramatically reduced their life options. Her compassion for these young women was based on her own lived experience. Espey had gotten pregnant the summer after her freshman year at Harvard; at 20, she was a single mother. But unlike the girls on the reservation, Espey was white and middle-class, and she had the wherewithal to finish college and go on to medical school.

She began to think about how to help these young women prevent pregnancy. She herself had recently been fitted with the new Paragard copper IUD. Why were not her physician colleagues as enthusiastic as she was about this method? Toward the end of the decade, she decided to investigate this question as part of her master’s thesis in public health. She dived into the medical literature and found research articles published more than 15 years earlier, in 1983, that should have supported IUD use.⁶¹ But timing is everything: these reports had come out at the height of the exposure of the Dalkon Shield disaster and were cited mainly as confirmation of the danger of that device.

A closer reading of the articles – one analyzed data from the Women’s Health Study of 622 women with pelvic inflammatory disease (PID) and 2369 controls in 16 hospitals in nine cities, while another used data from a similar case-control study of 155 cases and 305 controls from hospitals across the US and Canada – revealed that a disproportionately high number of women with PID had used the Dalkon Shield. In comparison, the other IUDs (Lippes Loop and copper IUDs) were much less risky, with the risk further decreasing a few months after insertion. But all IUDs were tarred with the same brush, and the Dalkon Shield took the others down with it.

The debate flared up again in the early 1990s with the publication of a provocative article by a biostatistician who had served as an expert witness for A. H. Robins in the Dalkon Shield trial in the 1980s, claiming that the Women’s Health Study and its conclusions were, in essence, hogwash.⁶² A flurry of rebuttals was published in the medical literature, but the damage might have been done. In a confusing editorial for Fertility and Sterility that purported to champion IUD use, David A. Eschenbach, chief of the Division of Gynecology at the University of Washington, presented an abundance of negative associations and inferences about the IUD. Statements such as “The IUD is a potential threat to future fertility” and “We need to stop trying to fool ourselves that in the case of the IUD infection is some abstract concept” would have been off-putting to the physician-reader looking for guidance on whether to fit patients with IUDs, in spite of Eschenbach’s begrudging acknowledgement of their utility in preventing pregnancy.⁶³

Undeterred, Espey decided to do her own study. Records of the Indian Health Service showed that the IUD had been very popular with Navaho women in the 1970s and early 1980s, chosen by some 40 percent of contraceptive users, but use rates had dropped dramatically when IUDs were taken off the American market. Even after the copper IUD was reintroduced via the Indian Health Service in 1993, it was used by only small numbers of women. Working with two other doctors, Espey developed and distributed a survey to health care providers at Navaho-serving facilities that asked clinicians about their knowledge, attitudes, and practices regarding IUDs. They noted a significant difference between women’s health providers (ob-gyns) and other primary care doctors (family physicians) in levels of experience and comfort in prescribing and inserting the devices, and they found a discrepancy between providers’ stated approval of IUDs and actual clinical practices. In spite of generally favorable attitudes, the devices were infrequently recommended and inserted. The biggest deterrent was a concern about the safety of IUDs, specifically, the risk of pelvic infection and infertility. Espey and her collaborators concluded, “Providers should receive education and training that emphasize the medical safety and high acceptability of current IUDs.” They went on to recommend, “training must target not only obstetrics and gynecology residents and nurse-midwife students, but also other providers who offer contraceptive counseling and may insert IUDs.”⁶⁴

In spite of this call to action for all physicians, Espey’s next move took her to the doorstep of the American College of Obstetricians and Gynecologists (ACOG). In doing background research for her study of Indian Health Service providers, she had come across an ACOG Technical Bulletin on IUDs published back in 1992, which she felt was outdated and provided misleading advice to practitioners. She wrote a letter to an ob-gyn with whom she had worked in Gallup who now held a leadership position in the College and asked if she could revise the bulletin. She got no reply, so several months later she wrote again. This time, somewhat to her surprise, she received a formal invitation to do the work. A few years before, she had moved to Albuquerque to take up a position at the University of New Mexico School of Medicine. And so, from her outpost in the Southwest, she set about to single-handedly draft the guidance that would eventually be issued from this august professional organization in Washington, DC.

Although the 1992 guide concluded, “the IUD is an excellent form of contraception for selected patients,” its approval was greatly tempered by a long list of potential complications: pelvic infection, displaced string, perforation, Actinomyces infections, and pregnancy. The entire tone of the piece was cautionary, starting with the first sentence: “Product liability and medical malpractice issues have had an impact on all contraceptive products, but none more so than the intrauterine device (IUD).” After reading the section on physician liability, ob-gyns may have concluded that the IUD simply was not worth the risk, either to their patients’ health or to their own wallets.⁶⁵

In contrast, the 2005 Practice Bulletin took a much more positive stance. Whereas the earlier version recommended IUDs only for “older, parous women,” the updated guide asserted in its very first sentence, “Intrauterine devices (IUDs) offer safe, effective, long-term contraception and should be considered for all women who seek a reliable, reversible contraceptive that is effective before coitus.” Side effects, such as headache, nausea, breast tenderness, and depression, resulting from the hormones in the levonorgestrel IUD (Mirena), were dismissed as “minimal.” Given that women had been experiencing similar hormone-related issues with oral contraceptives for the past 45 years, perhaps they had become normalized. Instead of “complications,” the 2005 guide offered a set of questions and answers under the heading of “Clinical Considerations and Recommendations,” in which myths were refuted and concerns were allayed by citing evidence from a vast body of published studies. The 2005 update listed 74 references; just 16 were listed in 1992.⁶⁶

Espey was part of a new generation of physicians brought up in the era of “evidence-based medicine.” This movement began in the 1980s and really took off in the 1990s. No longer content to treat patients based on individual experience or expert opinion or the “art” of medicine, these doctors believed that they must rely on “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”⁶⁷ Of course, what constituted the best evidence was not always evident. Nonetheless, by 2000, the expectation that reference would be made to evidence-based medicine had come to dominate medical education, health policy making, health insurance coverage, and the writing of clinical management guidelines. In this new climate, ACOG needed to update its practice bulletins, and it had turned to a young female physician to lead the way.

A similar effort was undertaken in the United Kingdom. In October 2005, the National Collaborating Centre for Women’s and Children’s Health released clinical guidelines on long-acting reversible contraception. Commissioned by the National Institute for Health and Clinical Excellence, the guidance was intended for health professionals in the National Health Service, healthcare commissioners, and women themselves. Like its American counterpart, the British document relied on published papers for its evidence base, but its final product was much more comprehensive, running to 192 pages with 451 references.⁶⁸

This guidance is notable for two additional reasons. First, it appears to be the first publication in which the acronym “LARC” – for long-acting reversible contraception – was used in print.⁶⁹ The British defined LARC as “methods that require administering less than once per cycle or month,” which included IUDs, implants, and injectables. In the United States, LARC came to mean multi-year birth control, thus excluding one-month and three-month injectables. (Eve Espey humorously referred to Depo-Provera as “the Pluto of birth control” because it was demoted from LARC, in much the same way as Pluto was demoted from full planet status in 2006.)

The British clinical guidelines also recommended IUDs for teenagers, with no restrictions. The January 2005 ACOG Practice Bulletin had made no mention of adolescents. It took another three years for ACOG to warm up to the subject. In December 2007, the College released a Committee Opinion specifically on adolescent use of the IUD. “Data support the safety of IUDs for most women, including adolescents,” it affirmed. “Because adolescents contribute disproportionately to the epidemic of unintended pregnancy in this country, top tier methods of contraception, including IUDs and implants, should be considered as first-line choices for both nulliparous and parous adolescents.”⁷⁰

Another professional organization, the American Academy of Pediatrics (AAP), was not willing to go that far. In November 2007, it released a wishy-washy policy statement on “Contraception and Adolescents” that provided information about available methods of birth control without strong endorsement of their use. “As advocates for the health and well-being of all young people,” the statement began, “the American Academy of Pediatrics strongly supports the recommendation that adolescents postpone sexual activity until they are fully ready for the emotional, physical, and financial consequences of sex.” It went on to acknowledge that “some young people will choose not to postpone sexual activity, and as health care providers, the responsibility of pediatricians includes helping teens reduce risks and negative health consequences associated with adolescent sexual behaviors, including unintended pregnancies and sexually transmitted infections.” Its recommendation on the IUD was circumspect: “IUDs have previously not been recommended for adolescents… however, an IUD may be appropriate for an adolescent who already has children.”⁷¹

By contrast, ACOG fully embraced the use of LARC to stem “the epidemic of unintended pregnancy.” A December 2009 Committee Opinion on “Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduced Unintended Pregnancy” reinforced the recommendation for clinicians to offer LARC as “first-line contraceptive methods.”⁷² Eighteen months later, ACOG’s Practice Bulletin on LARC (written to replace the original 2005 guidance on IUDs) stated unequivocally that “almost all women are eligible for implants and IUDs.” While Paragard had removed the “parous-only” indication from its package insert in 2005, Mirena still did not have FDA approval for use in nulliparous women. As with all drugs, physicians were to free to prescribe “off-label,” and ACOG took pains to provide other data that confirmed the safety and sanction of IUD use in women of any age who had not given birth. This revised Practice Bulletin drew the attention of the news media when it was released in the summer of 2011.⁷³ There was no contention; reports by Reuters, National Public Radio, and the Los Angeles Times merely repeated information from the ACOG document. In October 2012, the College replaced its 2007 Committee Opinion on adolescents and IUDs with expanded enthusiasm for LARC for teenagers; it, too, received widespread positive coverage.⁷⁴

In 2008, with support from an anonymous donor, ACOG established a LARC program to develop and disseminate up-to-date clinical information and educational materials for practitioners. The program distributed an electronic newsletter to ACOG members, with links to relevant studies in the medical literature, news about actions taken by agencies such as the Centers for Disease Control, information on available resources, and an introductory piece in each issue by the ACOG LARC work group chair, Eve Espey. The program developed educational slide sets, instructional videos, and on-line webinars for clinicians. It provided assistance and resources to help clinicians code their LARC prescriptions for proper insurance billing and reimbursement. It coordinated on-site trainings, marshalling the services of dozens of physicians to train their peers in the insertion and removal of IUDs and implants. The LARC program also established a presence at professional conferences, staffing booths in the exhibition hall at the annual meetings of the Association of Reproductive Health Professionals, the National Family Planning and Reproductive Health Association, Nurse Practitioners in Women’s Health, Medical Students for Choice, as well as ACOG. The LARC program booth offered the usual giveaways: pads, pens, flash drives, posters, and packets of information. All of these efforts were intended to raise the profile of long-acting reversible contraceptives among health care providers, to encourage them to incorporate these methods into their practices.⁷⁵

The anonymous donor (widely known to be the Susan Thompson Buffett Foundation, funded by the estate of the late first wife of Berkshire Hathaway investor Warren Buffett and by donations from Warren Buffett himself) also supported a large clinical study that was influential in shifting providers’ attitudes toward long-acting reversible contraception.⁷⁶ Launched in 2007 and led by faculty at Washington University in St. Louis, the Contraceptive CHOICE Project provided reversible contraception to over 9000 women for free and followed them for three years to find out whether removing the barrier of cost would encourage more women to use LARC methods and, if so, whether these contraceptives would lead to reduced rates of unintended pregnancy.

The answer to both questions was an unequivocal yes. Seventy-five percent of the study participants chose a LARC method (IUD or implant), and more women stuck with LARC methods than with non-LARC methods (pill, patch, ring, shot) for the duration of the study.⁷⁷ In comparison to national data, teenagers in the St. Louis area had significantly lower rates of pregnancy (34.0 vs. 158.5 per 1000), birth (19.4 vs. 94.0 per 1000), and abortion (9.7 vs. 41.5 per 1000).⁷⁸ Analysis of those pregnancies revealed that half of them resulted from contraceptive failure; furthermore, the risk of failure was 20 times higher for non-LARC methods than for LARC methods. This statistic was picked up by the news media and widely reported in print and on line.⁷⁹

The CHOICE Project proved to be a veritable boon for the researchers involved in the study who published more than 60 articles in medical journals between 2010 and 2018. Most of these articles appeared in journals for ob-gyns and other women’s health specialists, whose attitudes toward LARC appeared to become more positive. A survey of ob-gyns’ attitudes and practices about IUDs in 2000 (when only the copper IUD was available in the United States) found that physicians were very conservative in recommending IUDs to their patients, even though they believed the IUD to be a highly effective method of birth control.⁸⁰ Twelve years later, a different survey of ACOG Fellows showed that the large majority of respondents believed most women to be “good candidates” for IUDs.⁸¹ This enthusiasm, however, did not necessarily extend to physicians with different residency training. A 2015 study of residents in ob-gyn, family medicine, and pediatrics found vastly different comfort levels with IUDs and implants. While the ob-gyn residents reported high levels of comfort both in counseling about and inserting IUDs and implants, the family medicine trainees expressed lower levels, and the pediatricians reported the lowest levels of all, with many confessing their discomfort in speaking about and fitting LARC methods.⁸²

In 2014, the AAP released an updated policy statement on contraception for adolescents that acknowledged the shortcomings of abstinence counseling alone, affirmed the obligation of pediatricians to provide comprehensive and up-to-date contraceptive information, and endorsed LARC methods as “first line” choices for teenagers.⁸³ To make sure the message reached a wide audience among pediatricians, the organization’s monthly newsletter featured a story about the new recommendations on the cover of its October 2014 issue. Newspapers such as the Washington Post and the Chicago Tribune picked up the story and gave it a generally positive slant, as did reports on local television stations and on-line media sites. Perhaps not surprisingly, the far-right Breitbart News Network found contrarians who took issue with the AAP policy statement, such as the executive director of the American Association of Pro-Life Obstetricians and Gynecologists and the president of Human Life International, but most reports in mainstream outlets emphasized the higher efficacy of IUDs and implants as compared to condoms and birth control pills and linked this information to the persistently high rates of teen pregnancy in the United States to justify the endorsement and use of LARC.⁸⁴

The Debate Over “First Line” Promotion of LARC

The AAP policy statement served not as a starting point but rather as a belated acknowledgment of the preferential promotion of IUDs and implants to adolescents that had begun in earnest with the 2007 ACOG Committee Opinion. Advocacy of LARC as first line methods for teens was championed in a special supplement to the Journal of Adolescent Health published in April 2013. Wholly funded by the National Campaign to Prevent Teen and Unplanned Pregnancy (the private organization founded in 1996 in the wake of President Clinton’s call to action), this issue consisted of nine review articles and an editorial that sang the praises of LARC for young women. “For those of us who are old-timers,” the editorial began, “the term LARC may have snuck up on us … But it’s not a term we want to keep secret – in fact, we want to shout it from the rooftops: LARC = long-acting reversible contraception!”⁸⁵

The review articles built the case for why LARC methods were the best and how to decrease barriers to access and acceptance. One article explained how to debunk myths and misperceptions so that more young women would take up LARC, concluding that “The findings described here support the use of LARC as first-line contraception in adolescents.”⁸⁶ Another laid out a comprehensive strategy for counseling teenagers about contraception that recommended a tiered approach, “prioritizing more effective methods until the first good ‘match’ is found.”⁸⁷ In “Practical Tips for Intrauterine Device Use in Adolescents,” the author objected to the neutral presentation of all birth control options as equally valid. “Clinicians who care for adolescents,” she noted, “recognize that there are aspects of adolescent development that may make this nondirective counseling less than optimal.”⁸⁸

Critics of directive counseling in contraception (in which the provider played an active role in prioritizing the methods presented, as opposed to offering a neutral list or “cafeteria menu” of options) for all women, not just adolescents, soon made their positions known.⁸⁹ While acknowledging the effectiveness of IUDs and implants in preventing pregnancy and the value of having these LARC methods on the contraceptive menu, they raised three main concerns. First, emphasis on effectiveness as the most important criterion for selecting a method neglected the significance of other factors in individuals’ decision-making. Women also took into consideration potential side effects, feelings about hormones or having devices inserted in them, the ability to stop and start a method at will, and the role of their partners in contraception. Second, the implication that LARC on its own would reduce unintended pregnancy disregarded the complexities of women’s ambivalence about pregnancy and motherhood shaped by relational issues, cultural forces, and social structures. Third, LARC exuberance ignored the long history of reproductive coercion and injustice experienced by women of color and poor women. A study conducted in 2008 had found that clinicians were more likely to recommend an IUD to black and Latina low-income women than to white low-income women; no distinction by race or ethnicity was made for women of higher socioeconomic status. For white patients, providers were more inclined to recommend IUDs to those of low income compared to those of higher socioeconomic status; no such differentiation by income was made for black and Latina women.⁹⁰ The critics cautioned that unconscious bias could perpetuate the devaluing of reproduction among low-income women and women of color. Furthermore, such implicit assumptions about who should use LARC had the potential to reinforce the well-documented experiences of discrimination reported by black and Latina women receiving family planning services.⁹¹

Directive counseling in contraception was not new. Recall the favorable article that appeared in the American Journal of Public Health in 1996. The executive director of the National Women’s Health Network (NWHN) raised objections in a letter to the editor published in a subsequent issue of the journal: “Directive counseling for long-acting contraception is a mistake.”⁹² In the 2010s, facing renewed zeal among both policy advisers and health care professionals for the promotion of LARC as first-line methods, the Network attempted to draw a clear line between the right and wrong ways to counsel on and provide access to birth control. “We are encouraged by the tremendous progress made in the last 40 years in the design, safety, and efficacy of LARCs,” wrote the organization’s policy director. “Yet, the NWHN is deeply concerned that institutional enthusiasm for LARCs runs the risk of hampering individual women’s ability to decide what methods are best for their unique circumstances.”⁹³

The alternate model proposed by the NWHN and its allies was based on reproductive justice, a concept developed in the 1990s by women of color who were frustrated with the narrow focus of the mainstream reproductive rights movement on abortion alone.⁹⁴ Reproductive justice described efforts to build a world in which everyone had what they needed to create, sustain, and nurture the family they wanted in the way they wanted. It called for attention to issues of power structures and intersectionality – considering how race and class and other categories of analysis intersected with gender – in advocating for the marginalized. Reproductive justice was about both choice and access, not just to abortion and contraception, but also to things like alternative birth options, quality child care, and safe neighborhoods. In 2016, the NWHN joined SisterSong Women of Color Reproductive Justice Collective in a statement of principles rejecting “a one-size-fits-all focus on LARCs.”⁹⁵

It is interesting to note that the articles sounding the alarm about directive counseling were not authored by doctors or nurse practitioners. Health care providers who saw women in their clinics and practices continued to write enthusiastically about LARC promotion and how to increase the use of these methods, although they did acknowledge the issues raised by the critics. Reducing the rate of unintended pregnancy, especially among teenagers, remained a primary objective of expanding LARC uptake, and study after study reported on ways that providers could better facilitate access to IUDs and implants for their patients. One group described these efforts as an “important public health intervention,” which was exactly what concerned the critics, namely, that “the public health imperative plays a more significant role” than a woman’s own individual priorities.⁹⁶

In a 2019 interview, Eve Espey conceded that her efforts to make LARC more accessible could have been interpreted as pushing these methods over others. She believed strongly that her contraceptive counseling took into consideration the individual needs and circumstances of her patients, but she reflected that her message could have been interpreted differently, namely, to present LARC as superior to all other options. And as a thought leader among women’s health providers, her authoritative voice helped to guide a new generation of providers toward LARC enthusiasm. When “100 experts” were surveyed in 2015 about LARC use in the future, they predicted that the proportion of women choosing these methods would double (from 10-14 percent to 25-29 percent), and they championed the removal of existing obstacles, such as cost, providers’ inability to perform insertions (and removals), and women’s lack of knowledge of and comfort with IUDs and implants. Interestingly, these clinicians did not envision a majority of women on LARC, perhaps because of the persistence of and interconnections among existing barriers. They also heard the concerns of critics; the study authors noted that “their enthusiasm for policies to encourage LARC use was tempered by concern about the potential coercive effect of specific policies.”⁹⁷

Other LARC advocates skipped over the possibility of coercion. A 2018 article looked to the contraceptive practices of physicians themselves as a harbinger for future uptake of LARC by the general population. It reported that more than half of female residents in obstetrics and gynecology (or the female partners of male residents) had IUDs by 2016.⁹⁸ Their rate of use was five times that of the public. While the authors acknowledged that “Long-acting reversible contraceptive methods are not for everyone,” their conclusion emphasized what they considered to be the compelling argument in favor of LARC use: “decrease[d] unintended pregnancy, empowering women and saving billions of dollars in health care.”⁹⁹ By arguing for benefits to both individuals and society, these LARC proponents recycled arguments made by Margaret Sanger a century earlier.

The zeal for IUDs among these and other physicians and nurse practitioners helped to grow LARC use in the twenty-first century, from next to nothing to a sizeable proportion of contraceptive users in the United States. The authority of physicians, and especially ob-gyns, in the realm of contraception was reinforced in magazine articles, such as Glamour’s “The Birth Control Your Ob-gyn Uses.” Described as “the perfect low-maintenance birth control,” IUDs were presented as the thinking woman’s contraceptive.¹⁰⁰

No longer to be dismissed as a method discarded by American physicians and women alike, the IUD in 2020 enjoys status as a “five-star” method that works “really, really well… hassle-free” alongside the implant and sterilization, and ranking one star higher than the pill, which works “pretty well” but has to be used “Every. Single. Day.”¹⁰¹ This birth control hierarchy, produced as an eye-catching poster by the UCSF School of Medicine Bixby Center and the Bedsider Birth Control Support Network in 2017, illustrates the next era of contraceptive history, in which medically-controlled, long-acting methods are avidly promoted by health care providers and by journalists as the best choice for women, especially young women, who do not want to be sterilized. It also demonstrates the enduring authority of the medical profession in matters of contraception in the United States.

This work was supported by a fellowship in the History of American Obstetrics and Gynecology from the American College of Obstetricians and Gynecologists in 2018. The author wishes to thank Beth DeFrancis Sun at ACOG for her support during research visits to Washington, DC, as well as Aimee Medeiros, Elena Conis, Naomi Rogers, and the anonymous reviewers for their thoughtful comments and suggested revisions.

Footnotes

1

The historiography on birth control is vast and cannot be adequately summarized in a single footnote. Here, I highlight a very small percentage of the works that have informed my own, limiting these citations to books on contraception in the United States and (regrettably) leaving aside the scores of journal articles and book chapters that have moved forward our understanding of the histories of contraceptive technologies, feminisms, and reproductive health, rights, and justice. For broad surveys of contraception, see Linda Gordon, The Moral Property of Women: A History of Birth Control Politics in America (Urbana: University of Illinois Press, 2002), an updated version of her classic work, Woman’s Body, Woman’s Right (1976), and Andrea Tone, Devices and Desires: A History of Contraceptives in America (New York: Hill and Wang, 2001). On specific methods of contraception, see Lara Marks, Sexual Chemistry: A History of the Contraceptive Pill (New Haven: Yale University Press, 2001); Nelly Oudshoorn, The Male Pill: A Biography of a Technology in the Making (Durham: Duke University Press, 2003); Heather Munro Prescott, The Morning After: A History of Emergency Contraception in the United States (New Brunswick, NJ: Rutgers University Press, 2011); and Chikako Takeshita, The Global Biopolitics of the IUD: How Science Constructs Contraceptive Users and Women’s Bodies (Cambridge, MA: MIT Press, 2012). For works on contraception and reproductive justice, see note 94. For two very recent contributions, see Donna Drucker, Contraception: A Concise History (Cambridge, MA: MIT Press, 2020) and Jessica Borge, Protective Practices: A History of the London Rubber Company and the Condom Business (Montreal: McGill-Queen’s University Press, 2020).

2

Ellen Chesler, Woman of Valor: Margaret Sanger and the Birth Control Movement in America (New York: Simon & Schuster, 1992), 195.

3

Carole McCann, Figuring the Population Bomb: Gender and Demography in the Mid-Twentieth Century (Seattle: University of Washington Press, 2017).

4

Elizabeth Siegel Watkins, On the Pill: A Social History of Oral Contraceptives, 1950-1970 (Baltimore: Johns Hopkins University Press, 1998), 70.

5

Morton Mintz, At Any Cost: Corporate Greed, Women, and the Dalkon Shield (New York: Pantheon Books, 1985), 4.

6

Mintz, At Any Cost, 3-4. For a more recent and comprehensive analysis of the uses, interpretations, and meanings of IUDs in the Global North and South from the 1960s to the 2000s, see Takeshita, Global Biopolitics of the IUD.

7

“Are IUD contraceptives safe?” Good Housekeeping 177 (October 1973): 197.

8

“IUDs: Are they really safe?” Good Housekeeping 180 (January 1975): 127.

9

Jean Mufti, “A Young Mother’s Story, One Hundred and Sixty-ninth of a Series Written by Redbook Readers: The Baby I Loved and Lost,” Redbook 146 (March 1976): 62-63.

10

Shirley Vaughan, “A Birth Control Nightmare,” Good Housekeeping 187 (July 1978): 56-60.

11

C.M.R., “New warnings on IUDs,” Good Housekeeping 187 (September 1978): 258.

12

Edward S. Salsberg and Gaetano J. Forte, “Trends in the Physician Workforce, 1980-2000,” Health Affairs 21 (September/October 2002): 169.

13

“A Redbook Poll: What Doctors Recommend,” Redbook 151 (August 1978): 64.

14

Alice Lake, “The Pill: What We Really Know After 15 Years of Use,” McCall’s 102 (January 1975): 119.

15

Diane Stillman, “Birth Control: What the Experts Use,” McCall’s 107 (October 1979): 67.

16

ACOG Technical Bulletin #10, “Intrauterine Devices” (September 1968), 4. ACOG Resource Center, 409 12^th St., Washington, DC [hereafter, ACOG].

17

ACOG Technical Bulletin #10, “Intrauterine Devices” (September 1974), 4. ACOG.

18

ACOG Technical Bulletin #40, “The Intrauterine Device” (June 1976), 1. ACOG.

19

“Pill and IUD Use at PPFA Clinics Decline; Diaphragm Use Rises,” Family Planning Perspectives 14 (1982): 152.

20

Christine A. Bachrach, “Contraceptive Practice Among American Women, 1973-1982,” Family Planning Perspectives 16 (1984): 253-259, quote on 257. The significant changes in birth control use among married women over this nine-year period were decreased use of the pill (from 36.1% to 19.8%) and increased reliance on sterilization (23.5% to 41.0%).

21

William D. Mosher and William F. Pratt, “Use of Contraception and Family Planning Services in the United States, 1988,” American Journal of Public Health 80 (1990): 1132-1133.

22

Linda J. Piccinino and William D. Mosher, “Trends in Contraceptive Use in the United States: 1982-1995,” Family Planning Perspectives 30 (1998): 4-10.

23

“Searle Quits IUD,” Newsweek 107 (10 February 1986): 60.

24

“Manufacturer Halts Saf-T-Coil Production,” Contraceptive Technology Update 3 (September 1982): 109-110; “Ortho Stops Marketing Lippes Loop; Cites Economic Factors,” Contraceptive Technology Update 6 (November 1985): 149-152.

25

ACOG Technical Bulletin #104, “The Intruterine Device” (May 1987), 1. ACOG.

26

Mosher and Pratt, “Use of Contraception and Family Planning Services in the United States, 1988.”

27

Carl Djerassi, “Birth Control after 1984,” Science 169 (4 September 1970): 941-951; Carl Djerassi, “The Bitter Pill,” Science 245 (28 July 1989): 356-361.

28

Luigi Mastroianni, Jr., Peter J. Donaldson, and Thomas T. Kane, ed., Developing New Contraceptives: Obstacles and Opportunities (Washington, DC: National Academy Press, 1990).

29

Philip Elmer-DeWitt, “A Bitter Pill to Swallow,” Time 135 (26 February 1990): 44; Eloise Salholz, “Politics and the Pill,” Newsweek 115 (26 February 1990): 42; Doug Podolsky, “Sorry, Not Sold in the U.S.,” US News & World Report 109 (24 December 1990): 65; Peggy Orenstein, “The Politics of Birth Control,” Glamour 88 (October 1990): 264-267, 308-309; Reed Abelson, “Contraception Lives,” Forbes 146 (26 November 1990): 268-270.

30

Piccinino and Mosher, “Trends in Contraceptive Use in the United States, 1982-1995.” For historical studies of the implant and the shot, see Elizabeth Siegel Watkins, “From Breakthrough to Bust: The Brief Life of Norplant, the Contraceptive Implant,” Journal of Women’s History 22 (2010): 88-111, Elizabeth Siegel Watkins, “The Social Construction of a Contraceptive Technology: An Investigation of the Meanings of Norplant,” Science, Technology, and Human Values 36 (2011): 33-54; Wendy Kline, “Bodies of Evidence: Activists, Patients, and the FDA Regulation of Depo-Provera,” Journal of Women’s History 22 (2010): 64-87.

31

Polly F. Harrison and Allan Rosenfield, ed., Contraceptive Research and Development: Looking to the Future (Washington, DC: National Academy Press, 1996), 29.

32

Ibid., 239.

33

11 Million Teenagers: What Can Be Done About the Epidemic of Adolescent Pregnancies in the United States? (New York: Planned Parenthood Federation of America, 1976); Teenage Pregnancy: The Problem That Hasn’t Gone Away (New York: Planned Parenthood Federation of America, 1981).

34

Richard Woodbury, “High School Pregnancy,” Life (2 April 1971).

35

John F. Kanter and Melvin Zelnick, “Contraception and Pregnancy: Experience of Young Unmarried Women in the United States,” Family Planning Perspectives 5 (1973): 21-26.

36

Barbara Delatiner, “The Teenage Pregnancy Epidemic,” McCall’s 105 (July 1978): 45-52; John C. Kelly, “Epidemic: Teenage Pregnancy,” Family Health 10 (February 1978): 6-10. Dr. Kelly was the president of the American Academy of Family Practitioners.

37

Jack Slater, “The Growing Problem of Teen-Age Pregnancies,” Ebony 35 (March 1980): 53-58; Dorothy I. Height, “What Must Be Done About Children Having Children,” Ebony 40 (March 1985): 76-84; Marian Wright Edelman, “How To Prevent Teenage Pregnancy,” Ebony 42 (July 1987): 60-66.

38

Jerry Adler, “A Teen-Pregnancy Epidemic,” Newsweek 105 (25 March 1985): 90; Barbara Kantrowitz, “Kids and Contraceptives,” Newsweek 109 (16 February 1987): 54-65.

39

Cheryl D. Hayes, ed., Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing (Washington, DC: National Academy Press, 1987), 3-4.

40

Sarah S. Brown and Leon Eisenberg, ed., The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families (Washington, DC: National Academy Press, 1995), 1.

41

http://www.let.rug.nl/usa/presidents/william-jefferson-clinton/state-of-the-union-1995-(delivered-version).php. In his 1996 State of the Union address, President Clinton acknowledged both the decline in teen pregnancy rates and the formation of the National Campaign to End Teen and Unplanned Pregnancy:

“To strengthen the family we must do everything we can to keep the teen pregnancy rate going down. I am gratified, as I'm sure all Americans are, that it has dropped for two years in a row. But we all know it is still far too high. Tonight I am pleased to announce that a group of prominent Americans is responding to that challenge by forming an organization that will support grass-roots community efforts all across our country in a national campaign against teen pregnancy. And I challenge all of us and every American to join their efforts.”

https://clintonwhitehouse4.archives.gov/textonly/WH/New/other/sotu.html. The National Campaign was founded in 1996 as a private, non-profit organization with high-profile board members, such as former (Republican) governor of New Jersey Tom Kean and actress Jane Fonda. It worked with all types of media (especially television and internet) to deliver messages about pregnancy prevention to young people. For analytical critiques of the National Campaign’s approach to unplanned pregnancy prevention as neoliberal and market-based, see Clair Daniel, “‘Taming the Media Monster’: Teen Pregnancy and the Neoliberal Safety (Inter)Net,” Signs 39 (2014): 973-998, and Emily S. Mann and Patrick R. Grzanka, “Agency-Without-Choice: The Visual RHETORICS of Long-Acting Reversible Contraception Promotion,” Symbolic Interaction (2018) DOI: 10.1002/SYMB.349.

42

Brett Harvey, “The Great American Birth-Control Crisis,” Mademoiselle 95 (March 1989): 218.

43

Ibid., 219-220.

44

Nancy Gibbs, “The Vicious Cycle,” Time (20 June 1994): cover.

45

Ibid., 27.

46

Watkins, “From Breakthrough to Bust.”

47

Ellen Moskowitz and Bruce Jennings, “Directive Counseling on Long-Acting Contraception,” American Journal of Public Health 86 (1996): 787-790, quote on 787.

48

Jane E. Hutchings, Patti J. Benson, Gordon W. Perkin, and Richard M. Soderstrom, “The IUD After 20 Years: A Review of Worldwide Experience,” International Family Planning Perspectives 11 (1985): 77-86.

49

By comparison, 106 million took the pill. Watkins, “The Social Construction of a Contraceptive Technology,” 49.

50

See Betsy Hartmann, Reproductive Rights and Wrongs: The Global Politics of Population Control (Chicago: Haymarket Books, 2016), and Barbara Mintzes, Anita Hardon, and Jannemieke Hanhart, ed., Norplant: Under Her Skin (Delft: Eburon, 1993).

51

Takeshita, Global Biopolitics of the IUD, 100-101.

52

Susan S. Lang, “The New IUD: The Enemy Within?” Vogue 178 (August 1988): 230.

53

“IUDs Are Back,” Prevention 40 (April 1988): 14.

54

Susan Goodman, “The Return of the IUD,” Mademoiselle 94 (June 1988): 86.

55

Alison Stein Wellner, “The New No-Hassle Birth Control,” Ladies’ Home Journal 120 (October 2003): 160; Susan Brink, “Beyond the Pill,” U.S. News & World Report 133 (23 September 2002): 54-56.

56

Takeshita, Global Biopolitics of the IUD, 95.

57

Ad re-printed in Ibid., 96.

58

Mirena ad, Obstetrics & Gynecology (2001).

59

Hispanic women used IUDs in 2002 at a rate three and a half times greater than black women and white women, but the researchers provided no commentary on this disparity in their published article. William D. Mosher and Jo Jones, “Use of Contraception in the United States: 1982-2008,” Vital and Health Statistics Series 23, Number 29 (August 2010): 26-28.

60

Information about Eve Espey comes from a recorded interview with the author in Albuquerque, NM, on 3 October 2018. Transcript in the author’s possession. See also Jennifer Couzin-Frankel, “Contraceptive Comeback: The Maligned IUD Gets a Second Chance,” Wired (15 July 2011). https://www.wired.com/2011/07/ff_iud/ .

61

Nancy C. Lee et al., “Type of Intrauterine Device and the Risk of Pelvic Inflammatory Disease,” Obstetrics & Gynecology 62 (1983): 1-6; David W. Kaufman et al., “The Effect of Different Types of Intrauterine Devices on the Risk of Pelvic Inflammatory Disease,” Journal of the American Medical Association 250 (1983): 759-762; “Risk of PID 5x Greater From Dalkon Shield Than from Other IUDs,” Family Planning Perspectives 15 (1983): 225-226.

62

Richard A. Kronmal, Coralyn W. Whitney, and Stephen D. Mumford, “The Intrauterine Device and Pelvic Inflammatory Disease: The Women’s Health Study Reanalyzed,” Journal of Clinical Epidemiology 44 (1991): 109-122.

63

David A. Eschenbach, “Earth, Motherhood and the Intrauterine Device,” Fertility and Sterility 57 (1992): 1177-1179.

64

Eve Espey, Tony Ogburn, and Virgil Etsitty, “IUD-Related Knowledge, Attitudes and Practices Among Navajo Area Indian Health Service Providers,” Perspectives on Reproductive and Sexual Health 35 (2003): 169-173.

65

ACOG Technical Bulletin Number 164 (February 1992). Withdrawn in December 2001 and now out of print. ACOG.

66

ACOG Practice Bulletin Number 59 (January 2005). Replaced in July 2011 and now out of print. ACOG.

67

David L. Sackett et al., “Evidence Based Medicine: What It Is and What It Isn’t,” British Medical Journal 312 (1996): 71-72.

68

National Collaborating Centre for Women’s and Children’s Health (UK), Long-acting Reversible Contraception: The Effective and Appropriate Use of Long-Acting Reversible Contraception, NICE Clinical Guidelines, No. 30 (London: Royal College of Obstetricians & Gynecologists Press, 2005).

69

Ibid., viii. Long-Acting Reversible Contraception first appeared as a Medical Subject Heading in the National Library of Medicine’s curated medical vocabulary resource (MeSH) in 2018.

70

ACOG Committee Opinion Number 392 (December 2007). Replaced in October 2012 and now out of print. ACOG.

71

American Academy of Pediatrics Committee on Adolescence, “Policy Statement: Contraception and Adolescents,” Pediatrics 120 (2007): 1135-1148, quotes on 1135 and 1143.

72

ACOG Committee Opinion Number 450 (December 2009). Replaced in October 2015 and now out of print. ACOG.

73

ACOG Practice Bulletin Number 121 (July 2011). Out of print, but reaffirmed in 2015. ACOG. Amy Norton, “IUDs, Implants Advocated for Birth Control,” Reuters (21 June 2011); Linda Thrasybule, “Doctors: IUDs Deserve Another Look,” NPR (24 June 2011); Marissa Cevallos, “IUDs and Contraceptive Implants Recommended for Women,” Los Angeles Times (22 June 2011).

74

ACOG Committee Opinion Number 539 (October 2012). ACOG. Deborah Kotz, “Teens Can Get IUD’s and Contraceptive Implants, Doctors’ Group Says,” Boston Globe (21 September 2012); “Medical Group Says Teens Should Use IUDs, Implants as First Contraceptive Method,” CBS News (21 September 2012); Amy Norton, “IUDs, Implants Encouraged for Teenage Girls,” Reuters (24 September 2012); Brian Alexander, “IUDs, Implants Best for Birth Control, Even for Teens, Docs Say,” NBC Today Health (20 September 2012).

75

Interview with Alicia Luchowski, director of the ACOG LARC program, by the author at the ACOG headquarters in Washington, DC, on 7 August 2018. Transcript in the author’s possession. See also https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/LARC-Program-Activities.

76

https://www.influencewatch.org/non-profit/susan-thompson-buffett-foundation/.

77

Colleen McNicholas et al., “The Contraceptive CHOICE Project Round Up: What We Did and What We Learned,” Clinical Obstetrics and Gynecology 57 (2014): 635-643; Micaela O’ Neil-Callahan et al., “Twenty-Four-Month Continuation of Reversible Contraception,” Obstetrics & Gynecology 122 (2013): 1083-1091. Some observers have questioned whether the presentation of LARC methods as more effective than other methods nudged women to choose the former over the latter. See Emily S. Mann and Patrick R. Grzanka, “Agency-Without-Choice: The Visual RHETORICS of Long-Acting Reversible Contraceptive Promotion,” Symbolic Interaction (2018), 16.

78

Natalia E. Birgisson et al., “Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review,” Journal of Women’s Health 24 (2015): 349-353; Gina M. Secura et al., “Provision on No-Cost, Long-Acting Contraception and Teenage Pregnancy,” New England Journal of Medicine 371 (2014): 1316-1323.

79

Brooke Winner et al., “Effectiveness of Long-Acting Reversible Contraception,” New England Journal of Medicine 366 (2012): 1998-2007.

80

Nancy Stanwood, Joanne M. Garrett, and Thomas R. Konrad, “Obstetrician-Gynecologists and the Intrauterine Device: A Survey of Attitudes and Practice,” Obstetrics & Gynecology 99 (2002): 275-280.

81

Alicia T. Luchowski et al., “Obstetrician-Gynecologists and Contraception: Long-Acting Reversible Contraception Practices and Education,” Contraception 89 (2014): 578-583, quote on 581.

82

Susan A. Davis et al., “Familiarity with Long-acting Reversible Contraceptives among Obstetrics and Gynecology, Family Medicine, and Pediatrics Residents: Results of a 2015 National Survey and Implications for Contraceptive Provision for Adolescents,” Pediatric Adolescent Gynecology 31 (2018): 40-44.

83

American Academy of Pediatrics Committee on Adolescence, “Policy Statement: Contraception for Adolescents,” Pediatrics 134 (2014): 1244-1256, quote on 1251.

84

Hilary Rasch, “‘Start the Dialogue’: Physicians Urged to Counsel Teens, Ensure They Have Access to Contraceptive Services,” AAP News 35 (October 2014); Elahe Izadi, “Pediatrics Group Recommends IUDs, Implants as Best Birth Control for Teen Girls,” Washington Post (29 September 2014); Bonnie Miller Rubin, “Sexually-Active Teens Should Get IUDs: Doctors Group,” Chicago Tribune (2 December 2014); Susan Berry, “American Academy of Pediatrics Urges IUDs, Contraception for Teen Girls,” Breitbart.com (18 October 2014).

85

Paula J. Adams Hillard, “What is LARC? And Why Does It Matter for Adolescents and Young Adults?” Journal of Adolescent Health 52; 4S (2013): S1.

86

Jennifer A. Russo, Elizabeth Miller, and Melanie A. Gold, “Myths and Misperceptions About Long-Acting Reversible Contraception (LARC),” Journal of Adolescent Health 52; 4S (2013): S19.

87

James Jaccard and Nicole Levitz, “Counseling Adolescents About Contraception: Towards the Development of an Evidence-Based Protocol for Contraceptive Counselors,” Journal of Adolescent Health 52; 4S (2013): S10.

88

Paula J. Adams Hillard, “Practical Tips for Intrauterine Device Use in Adolescents,” Journal of Adolescent Health 52; 4S (2013): S40. Hillard reiterated her support for directive counseling in a recorded interview with the author on 31 August 2019 at Stanford Hospital in Stanford, CA. Transcript in the author’s possession.

89

Jenny A. Higgins, “Celebration Meets Caution: LARC’s Boons, Potential Busts, and the Benefits of a Reproductive Justice Approach,” Contraception 89 (2014): 237-241; Anu Manchikanti Gomez, Liza Fuentes, and Amy Allina, “Women or LARC First? Reproductive Autonomy and the Promotion of Long-Acting Reversible Contraceptive Methods,” Perspectives in Sexual and Reproductive Health 46 (2014): 171-175.

90

Christine Dehlendorf et al., “Recommendations for Intrauterine Contraception: A Randomized Trial of the Effects of Patients’ Race/Ethnicity and Socioeconomic Status,” American Journal of Obstetrics and Gynecology 203 (2010): 319e1-8.

91

Gomez, Fuentes, and Allina, “Women or LARC First?” 171.

92

Cynthia A. Pearson, “Directive Counseling Should Emphasize Disease Protection, Not Pregnancy Prevention,” American Journal of Public Health 87 (1997): 1868.

93

Coco Jervis, “The Great LARC Debate: Facilitating a Balanced Approach to Education and Promotion of LARCs,” The Women’s Health Activist 40 (September/October 2015): 4-5.

94

For a comprehensive introduction to the concept of reproductive justice and its location within the longer history of reproductive politics, see Loretta J. Ross and Rickie Solinger, Reproductive Justice: An Introduction (Berkeley: University of California Press, 2017). See also, Dorothy Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (New York: Random House, 1997); Jennifer Nelson, Women of Color and the Reproductive Rights Movement (New York: NYU Press, 2003); Jael Silliman, Marlene Gerber Fried, Loretta Ross, and Elena R. Gutierrez, Undivided Rights: Women of Color Organize for Reproductive Justice (Chicago: Haymarket Books, 2004); Barbara Gurr, Reproductive Justice: The Politics of Health Care for Native American Women (New Brunswick, NJ: Rutgers University Press, 2014); and Loretta Ross, Radical Reproductive Justice: Foundation, Theory, Practice, Critique (New York: The Feminist Press at CUNY, 2017).

95

Sarah Christopherson, “NWHN Joins Statement of Principles on LARCs,” The Women’s Health Activist 41 (November/December 2016): 9. See also https://www.nwhn.org/?s=larc+principles.

96

Somsook Santibenchakul et al., “Promotion of Long-Acting Contraception Among Adolescents and Young Adults,” Journal of Midwifery & Women’s Health (2018) DOI: 10.1111/jmwh.12934, 1; Gomez, Fuentes, and Allina, “Women or LARC First?” 173.

97

Diana Greene Foster et al., “Projections and Opinions from 100 Experts in Long-Acting Reversible Contraception,” Contraception 92 (2015): 543-552, quote on 550.

98

Megan L. Evans et al., “Use of Long-Acting Reversible Contraception by Obstetrics and Gynecology Residents: An Examination of Access for All Women,” Obstetrics & Gynecology 131 (2018): 538-541.

99

Ibid., 540.

100

Kaitlin Menza, “The Birth Control Your Ob-gyn Uses,” Glamour 109 (September 2011): 266.

101

“How Well Does Birth Control Work?” Laminated poster. UCSF School of Medicine Bixby Center and Bedsider. August 2017. In the author’s possession.