Christine Dehlendorf and Kelsey Holt :
Over the past decade, more and more women have begun using long-acting, reversible birth control methods like intrauterine devices and implants. These birth control methods are highly effective at preventing pregnancy but were previously not widely accessible because of high costs and lack of knowledge among health care providers. Increasing access to these methods, for women who want them, is a sign of progress.
However, many researchers, advocates and policymakers aren’t selling their rise solely as a victory for women’s health. They claim IUDs and implants may be a powerful new tool to fight poverty. This sort of language should set off alarm bells because the idea that limiting women’s reproduction can cure society’s ills has a long, shameful history in the United States.
Between 1909 and 1979, about 20,000 people were involuntarily sterilized in California – one of 33 states where compulsory sterilization in the name of eugenics and social well-being was legal in the 20th century. In the 1990s, multiple states proposed laws to incentivize or even require welfare recipients to use the new contraceptive Norplant – and while none of these became law, they helped shape public discourse. Even in recent years, some judges have offered reduced sentences to defendants who agree to be sterilized or use birth control. All of the above are instances in which the state sought to limit the reproduction of the poor, people of color and other groups, because of a belief that doing so would be for the good of society.
Today, this age-old idea that reproduction is to blame for societal problems has seen a resurgence in the current enthusiasm around long-acting, reversible contraception.
We can see echoes of this view in how some politicians argue for expanded access to birth control as a tool to address intergenerational poverty. We can see it in the priorities of philanthropic funders and in glowing media coverage about the promise of long-acting birth control that produces headlines like “Can the IUD Prevent Poverty, Save Taxpayers Billions?”
Promoting IUDs and implants is certainly less egregious than state-sponsored eugenics. But promoting them from a poverty-reduction perspective still targets the reproduction of certain women based on a problematic and simplistic understanding of the causes of societal ills. Such tactics could also, ironically, harm the quality of family-planning care for the very women they are intended to help.
Of course contraception is critical to individuals’ human right to control their reproduction and shape the course of their own lives. But there is a clear danger in suggesting that ending poverty on a societal level is as simple as inserting a device into an arm or uterus. This idea distracts from the structural factors – like the availability of social services and racial discrimination – that determine economic opportunities. Providing contraception is critical because it is a core component of women’s health care, not because of an unfounded belief that it is a silver bullet for poverty. We also have concerns about how this emphasis on birth control as a tool of poverty reduction actually plays out in clinics. Claims about the social benefits of increasing the use of IUDs and implants can contribute to a narrative that says these methods are the best methods for everyone and that a program’s success should be judged by the numbers of IUDs and implants its providers insert. This, in turn, can contribute to providers neglecting individual women’s preferences when it comes to birth control: applying subtle pressure to use long-acting contraception, for example, or resisting requests to remove IUDs and implants.
These concerns about the quality of family-planning care are particularly salient for women of color. Research has shown that black women are more likely to feel pressured to use contraceptives. When studying counseling about IUDs specifically, we found that providers are more likely to recommend IUDs to low-income black and Latina women than low-income white women.
Given these biases, and the long history of coercion, it is no wonder that research has found that more than 40 percent of black and Latina women think the government promotes birth control to limit births among communities of color. Such beliefs should not be dismissed as conspiracy theories but recognized as understandable reactions to lived experiences. Programs to promote long-acting methods among women of color can further erode trust in family-planning services. Indeed, women of color have led efforts to raise awareness about the dangers of these programs and define principles for respectful provision of these methods.
Prioritizing women’s access to all contraceptive methods is undeniably a laudable goal. But access shouldn’t be contingent on the dangerous claim that it will address the fundamental societal problem of poverty and economic inequality. This, in fact, requires policies such as raising the minimum wage, instituting paid family and sick leave, and expanding access to social services.
Instead, policies and programs around family planning should keep their focus where it belongs: on whether women’s needs are met and their preferences for building – or not building – a family are respected. These efforts should explicitly acknowledge and respond to the continuing bias in health care and the mistrust many women feel in family-planning services. In doing so, they can begin to address the dark history of reproductive coercion and ensure all women receive the care that they deserve.
(Christine Dehlendorf, a family physician, and Kelsey Holt, a social and behavioral scientist, are researchers with the Person-Centered Reproductive Health Program at the University of California, San Francisco).
