Long-acting reversible contraception deserves tentative conservative support
Usually one makes the case for a policy before enacting it. Not so with the Left’s new push to promote long-acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs) and hormone-dispensing implants. Acting on authority given it by the Affordable Care Act, in 2012 the Obama administration’s Department of Health and Human Services mandated that insurance plans cover these forms of birth control without a co-pay, thus eliminating the high up-front cost that steers many women toward other methods. But it wasn’t until more recently that prominent left-leaning analysts, most notably Isabel V. Sawhill of the Brookings Institution, made a detailed argument that wider use of these devices could actually reduce unwanted pregnancy despite the failure of earlier contraceptive-pushing campaigns to achieve that goal.
Many conservatives won’t get behind a government policy to socialize the cost of contraception, especially after the administration tried to force the mandate on objecting religious employers. But given their deep concerns about abortion and out-of-wedlock births, should those on the right at least see the upside here, and perhaps go along with a cultural campaign to encourage the use of LARCs?
The answer is a qualified yes. The case for LARCs, unlike previous liberal arguments for promoting birth control, actually squares with the facts of how unwanted pregnancies happen. LARCs are the best chance we have for reducing abortion and unwed parenthood, and it’s possible they could be good for marriage too. However, pro-lifers raise legitimate questions about whether IUDs can themselves destroy embryos by preventing them from implanting in the uterus, and, as always, conservatives should be wary of the potential for unintended consequences.
Such suspicion is understandable because until now, the Left’s argument that abortion and unwed parenthood stem from a lack of birth-control access could not pass the laugh test. Even before the contraception mandate, birth control was widely available. Just about every retail store and gas station sold condoms; colleges, Planned Parenthood clinics, and some major cities provided contraceptives for free; most insurance plans covered birth-control pills with a modest co-pay; Medicaid provided the Pill to the poor; and Target and Walmart made the Pill available for as little as $9 a month.
Other data bear this out. Roughly half of unplanned pregnancies are in women who actually were using birth control — just not (in the vast majority of cases) very consistently. When the other half are asked why they didn’t try to avoid pregnancy, they rarely point to a lack of contraceptive access. In other words, while both condoms and the Pill are very effective when used correctly, they are quite often not used correctly or not used at all, no matter how available they are. Over the course of a year, 18 percent of condom users (i.e., women whose partners wear condoms) and 9 percent of Pill users will become pregnant, as compared with 85 percent of sexually active women who use no contraception. Roughly half of these unintended pregnancies result in abortion, the other half in unintended children. There are about a million abortions per year in the U.S., and 40 percent of all children are born out of wedlock.
Further complicating the Left’s case for mandatory contraceptive coverage, the line between “intended” and “unintended” pregnancy is not particularly clear for poor, unmarried women. In many cases their failure to use contraception is not completely accidental. They often characterize their pregnancies as “not exactly planned” and yet “not exactly avoided,” as documented in Promises I Can Keep, a book by sociologists Kathryn Edin and Maria J. Kefalas. Sawhill, in her book Generation Unbound, calls these parents “drifters,” as opposed to “planners” — they roll the dice until they become pregnant and deal with parenthood from there, rather than carefully choosing the best time to have a child.
To be sure, it’s possible that expanding access to traditional forms of birth control, for example by selling the Pill over the counter, could have some effect at the margins. For example, about 10 percent of Pill users who have abortions say their supply ran out. And though the evidence on sex education is mixed at best, there are signs that ignorance contributes to unintended pregnancy too: When asked why they had sex without protection, some mothers say they didn’t think they could get pregnant, for one reason or another. But beyond these special cases, pushing more condoms and pills at people is not a promising strategy.
This is where LARCs are different. With an IUD or hormone-dispensing implant, a woman who wants to have a child someday but realizes she isn’t ready yet can make her decision rationally and then forget about it. To avoid pregnancy, she no longer has to take a pill every day or insist in the heat of the moment that her partner wear a condom; instead, the LARC will remain effective for years, and she’ll need to have it removed if she wants to get pregnant. Women using IUDs have annual pregnancy rates under 1 percent, with rates for implants as low as 0.05 percent — meaning that abortions and unintended children are exceedingly rare in this demographic. The potential here is obviously high.
Beyond the immediate effect of reducing unplanned pregnancies, expanded use of LARCs could have benefits for marriage. In low-income and especially African-American communities, “marriageability” can be a serious problem. Men are often unemployed or incarcerated, making them unappealing (or unavailable) marriage partners for women, while women often have children by previous partners, making them unappealing marriage partners for men. When, with a LARC, a woman delays childbearing until she is older, she preserves her own marriageability in the event that the right partner comes along, and she can increase the likelihood that the right partner will come along — not just because she can spend more time looking, but also simply by aging, because her age cohort will include older men who are farther along in their careers, more willing to settle down, and less likely to be behind bars. Even if a woman decides to remove the LARC and have a child without getting married, she will be more mature and more financially secure for having waited. And she will have done so by making a decision, not through accident, inattention, or a half-hearted desire to avoid pregnancy.
Many conservatives might prefer to bring back the marriage culture that America enjoyed decades ago, but the bottom line is that marriage changed because the incentives for marriage changed — and those incentives are not changing back. In the first half of the 20th century, before the Pill and abortion became widely available (though condoms were), premarital sex was already becoming common. Because it was not feasible for a woman to raise a child on her own, pregnancies often resulted in “shotgun” marriages. These marriages endured, in part, because women had few economic opportunities if they left their husbands (who could usually support a family even without much education) and the government provided little help to single mothers.
Today, educated women can pursue the careers of their choice before settling down, uneducated women find that most of the men around them are not reliable providers, and birth control holds out the promise of years of premarital, pre-parenthood sexual activity. Delayed marriage can be good, because marriages formed later tend to be more stable, but lower-class women in particular often slip up and bear children earlier than planned. No shotgun marriage is forthcoming when this happens — having the child was her choice, after all, and government programs ensure that children won’t go hungry even when a mother can’t provide and the father is absent. (Upper-class women get pregnant, too, but are more willing to have abortions when contraception fails.)
Giving women more control over their fertility is the most promising way to address this situation. It’s not as if we’re going to ban birth control, eject women from the workplace, make abstinence until marriage even more common than it was before the sexual revolution, talk today’s youth into marrying in their teens or early 20s, or eliminate welfare for single moms and their children. And wider use of LARCs is entirely compatible with the more modest policies conservatives are actually advancing, such as gently restructuring welfare programs to encourage more responsible decisions.
The tradeoffs here are complicated, however, for pro-lifers who believe that legal protection for human life should begin at the instant an egg is fertilized — i.e., before the embryo implants in the uterus — and suspect that IUDs sometimes work by preventing implantation. While I don’t share these pro-lifers’ view about the value of unimplanted embryos, the evidence suggests that IUDs do sometimes work this way, perhaps often enough to make them a no-go for those who hold this opinion. If an unimplanted embryo is a human life worth protecting, this has ramifications far beyond IUDs. It also brings to our attention the fact that many pregnancies end naturally when the embryo fails to implant, and women don’t even notice. Estimates vary widely, but this likely happens hundreds of thousands to millions of times every year in the U.S. (For comparison, there are about 35,000 motor-vehicle fatalities and 600,000 cancer deaths per year.) Research into this phenomenon is still in its early stages, but at least part of the story seems to be that women’s bodies are designed to destroy embryos with genetic abnormalities, in a sort of natural eugenics, and sometimes this process is miscalibrated and healthy embryos are destroyed too.
It’s not enough to refrain from killing human beings; we also need to prevent natural death whenever we can, even at considerable expense, and even if the person has a genetic disorder. This is the approach we take not only after birth, but also (abortion, horrifyingly, aside) with fetuses at later stages of development. A serious attempt to minimize these deaths could include drugs to reduce the risk of implantation failure, tests to make sure women’s embryo-destroying apparatuses are not overly sensitive before they try to conceive, or even, eventually, pre-screening eggs and sperm for abnormalities and managing the fertilization process in artificial wombs. This conclusion — a pro-life war on natural childbearing — is absurd enough to call into serious question the premise that unimplanted embryos must be protected.
Nonetheless, many conservatives and religious people believe life should be protected from the moment of fertilization, and the Left has rarely taken seriously their concerns about one type of LARC: IUDs, small devices that are placed in the uterus and prevent pregnancy through mechanisms that are not fully understood. One does not take these concerns seriously, for example, by noting that IUDs “typically” don’t destroy embryos, or by pointing out that medical professionals now define pregnancy so that it begins at implantation. An exception is the science journalist Maggie Koerth-Baker, who supports abortion rights but has written an excellent, balanced summary of the research on how often IUDs prevent implantation.
From research that tracks hormone levels, the presence or absence of fertilized egg cells, and other data, Koerth-Baker concludes that IUDs usually do their work before fertilization occurs, though they probably also stop implantation from time to time. To many on the left, that’s good enough. For example, the ob-gyn Jen Gunter, in a much less balanced summary of the research for The New Republic (to which the pro-life ob-gyn Donna Harrison responded on National Review Online), conceded that it’s possible that copper IUDs destroy embryos in 1 percent of a sexually active user’s cycles — but emphasized that this is a “very small percentage.”
To be sure, even to a staunch pro-lifer, some percentage might be acceptable. The occasional, inadvertent destruction of an embryo is not the same thing as an intentional abortion — we take the risk of killing ourselves, our passengers, and other drivers every time we get on a highway, and yet no one wants to ban highways. But at some point, putting others at risk for your own convenience becomes intolerable, a fact the law recognizes in its treatment of negligence, endangerment, etc. Where do IUDs fall on this spectrum?
Let’s start with Gunter’s 1 percent of cycles, which is around the middle of the estimates Koerth-Baker compiled. That is indeed a very small percentage, but it adds up quickly because cycles repeat every 30 days or so. On average, a woman will experience one abortion for every eight years of copper-IUD use. This is far beyond the risk of something like a car: If the average driver killed someone every eight years, we would take action. Certainly, someone who firmly believes that an unimplanted embryo holds the same moral value as any other human life might not want to use IUDs herself, and she even might aspire, down the line in a post–Roe v. Wade world, to ban them. (Of course, the math will change if further research shows the risk to be much lower than 1 percent, or if a given pro-lifer sees these embryos as having somewhat less value than other human lives.)
But even these pro-lifers should bear in mind that increasing IUD use will not result in a situation dramatically different from the status quo, given the legal protection that abortion enjoys. Recall that 9 percent of Pill users, 18 percent of condom users, and 85 percent of those not using contraception get pregnant over the course of a year, and that half of unintended pregnancies end in abortion. Very roughly, this works out to one abortion — plus an unintended birth — for every 22 years of Pill use, every eleven years of condom use, and every two and a half years without birth control. (Not to mention that the Pill itself may sometimes work by preventing implantation.) All else being held constant, shifting women from these methods (or non-methods) to IUDs would decrease unintended childbearing, might be a wash when it comes to the total number of abortions (depending on what types of birth control women abandon for IUDs), and would ensure that the abortions that occurred did so very early.
One concern, though, is that all else isn’t held constant — a point that the political scientist Michael J. New has been making for years. Studies of programs that provide free birth control have often found no reduction in abortion or unintended childbearing, perhaps because of “risk compensation,” in which women respond to easier access to birth control by having more sex. And women who take the Pill are less likely to make their partners use condoms, thus increasing their risk of an STD. One recent study, however, showed no increase in risky sexual behavior among women in areas that expanded access to emergency contraception.
LARCs are so effective that they’re virtually certain to reduce pregnancy among women who use them. However, increased sexual activity and decreased use of condoms may also be results. This could mean more sexually transmitted disease, though conservatives should find it acceptable to transfer the dangers of promiscuity from unintended children (born and unborn) to the adults who actually engage in the promiscuity.
More worrisome is the possibility that increased sexual activity will undermine these individuals’ future marriages. People with more premarital sex partners have higher infidelity and divorce rates, though it’s hard to say whether this is cause and effect or just two different manifestations of the same personal traits (and multiple previous sex partners are undoubtedly less harmful to a marriage than is a child from a prior relationship). It’s even imaginable that an increase in sexual activity stemming from LARCs could diffuse into the broader culture, encouraging the many women who are not on LARCs to change their behavior as well. (Even in a St. Louis program designed to promote LARCs and give them away for free, about a quarter of participants chose other forms of birth control.) These effects will probably be small in relation to the abortions and unintended births prevented, but they cannot simply be dismissed.
Conservatives have long lamented the decline of the family and the rise of legal abortion, and both problems have been difficult to address in any significant way. LARCs may be the key to changing that, especially given the support they enjoy from the left. Conservatives need not support the Obama administration’s heavy-handed approach to imposing these devices to recognize their potential.