For a long time, I’ve wondered how easy it is for poor women to get IUDs removed. Long active reversible contraception (LARCs) are strongly recommended for poor women, but they can face the greatest barriers to seeing a doctor, and can be stuck, unable to have the children they want. I was glad to get to research this for the Institute for Family Studies.
The glossy tone of the [contraceptive program] ad camouflages this reality, framing birth control as an expansive way of life, rather than a response to a narrowing of a woman’s options. But behind the PSAs, the advisories for doctors are more candid about how LARCs fit into a culture that disempowers women.
Part of the case for LARCs, as explained by the Maryland Health Department, is that vulnerable women have only limited access to health care. Pregnancy and the immediate post-partum period might be the only time that vulnerable women can afford to see a doctor, since their pregnancy makes them eligible for Medicaid. The coverage lasts only two months post-partum, so the window for follow-up care is narrow. A woman who expresses a wish for a LARC at her six-week follow up may have only two weeks to receive it before her coverage lapses. Significant proportions of mothers do not make it to their six-week visit at all.
Thus, the American College of Obstetrics and Gynecologists (ACOG) recommendation is to take advantage of the moment when “the woman and clinician are in the same place at the same time.” The ideal, according to ACOG, is to place the IUD “within 10 minutes of placental delivery in vaginal and cesarean births.” In some hospitals, that may mean the IUD preventing future births is placed before the present baby has been handed to his or her mother. The ACOG notes that IUD placement immediately post-partum has a higher failure rate (where the IUD is expelled) than placement later after birth. But they estimate that a poorer success rate is better than a purely hypothetical higher success rate. If a later appointment is impossible, then the success rate is nil.
The ACOG covers some possible counterindications and topics for discussion with women considering post-partum IUDs or implants. But they do not suggest doctors ask the question: “Do you have a plan for obtaining care to remove your IUD or implant when you are ready?”
[…]A woman who relies on an IUD depends on a doctor to be able to have children again. If IUDs are specifically recommended to women who have difficulty accessing medical care, these will also be the women who face the most obstacles to being able to conceive the children they want.