Dec. 15 2015

How Obamacare Explains the Rising Popularity of IUDs

Carolyn Westhoff Takes Us on a Tour of 55 Years of Changing Attitudes and Preferences Toward Contraception

In the hullabaloo around the Affordable Care Act, there has been little attention to the law’s effect on birth control. Under the ACA, private health plans are required to cover contraception without co-pays or deductibles, making birth control of many different varieties available to more women than ever before. And beginning sometime next year, women in California and Oregon will be able to get several types of birth control from their pharmacists without a prescription.

The road to the current status quo on birth control has been long and winding. In the first half of the 20th century, activists like Margaret Sanger helped change the laws around birth control and sex education in the United States. Her American Birth Control League eventually became Planned Parenthood. Then came the birth control pill. Introduced in 1960, "the Pill" ushered in the sexual revolution and an array of birth control options that in the decades since have waxed and waned in popularity.

“This has been the era for modern contraception,” says Carolyn Westhoff, professor of Obstetrics and Gynecology, Epidemiology and Population and Family Health.

By 1967, the year the Pill was featured on the cover of TIME magazine, 13 million American women were using it. According to Westhoff, who is also senior medical advisor for Planned Parenthood (currently approaching its 100th year of providing comprehensive sex education and clinical services), women were particularly excited about a method that did not need to be on-hand during intercourse—and had proven to be more effective than diaphragms and condoms.  

But by the late 60s, the Pill lost some of its allure as information came out about side effects ranging from blood clots to breast tenderness, nausea, and breakthrough bleeding. In the context of mounting media coverage about the risk of blood clots, Senator Gaylord Nelson convened hearings on the safety of the Pill. Soon after, the Food and Drug Administration asked manufacturers to revise their labeling to reference its risks. As a consequence, sales dropped by 20 percent.

Boom and Bust

Thus began what is commonly known as the “boom and bust” cycle of contraception: enthusiastic adoption, followed by extreme disillusionment.

“Contraceptive methods are not one-size fits all,” says Westhoff, and the pendulum of popularity swings a lot for every method.”

For example, when the intrauterine device (IUD) was first introduced in the '60s, it was heralded as a safe, non-hormonal alternative to the birth control pill. But in that pre-AIDS era, there were no screenings for sexually transmitted disease, and when some women developed pelvic inflammatory infections, the IUD was blamed. By 1984, the IUD virtually disappeared. With growing awareness of the risk of sexually transmitted infections around the AIDS epidemic, condoms use climbed in 1980s.

The following decade saw the arrival of Norplant, the first hormonal contraceptive implant. Because no daily action was required, Norplant was touted for both its ease and reliability, marketed by the slogan, “as perfect a method as you can have.” Many women felt otherwise. More than 20 class action lawsuits were filed against its manufacturer, claiming excessive pain when the device was removed as well as depression, stroke, vaginal bleeding, and weight gain. Although none of the complaints were proven, the manufacturer withdrew Norplant from the market due to dwindling sales that resulted from the adverse publicity.

Continuing Coverage

Despite their worries about side effects and risks, women continue to use birth control to avoid or time child-bearing. In fact, 90 percent of American women who have heterosexual sex and do not want to be pregnant use a method of contraception.

“In general, women are working hard to avoid pregnancy,” says Westhoff. “What changes over time is what methods are available to them.”

The broad coverage of birth control methods under the Affordable Care Act ushered in another sea change. So far, the IUD is the biggest beneficiary. New data since the 1980s provided reassurance about IUD safety, but use remained low, partly due to the expense of the available devices. Between 2011 and 2013, use of this long-acting reversible implantation method doubled as its price to consumers dropped from hundreds of dollars to effectively nothing. Today, one in ten American women using birth control uses an IUD.

According to Westhoff, birth control experts and public health officials are making a deliberate effort to correct some of the earlier myths about IUDs and re-introduce the method to a new generation of women. Meanwhile, research into IUDs continues. Westhoff is currently working on two clinical trials evaluating the long-term effects of new hormonal and copper versions.

“Ultimately, it’s great to have options,” says Westoff. “Every woman should have enough information to decide for herself what method is best, and have access to that method.”