Nikki Lee Health

When I was growing up, birth control meant a variety of things: vaginal cream, diaphragms, condoms, the rhythm method, and the Pill.  Today, when someone says “I’m on birth control”, everyone knows they mean hormonal stuff. How did birth control come to mean only hormonal methods?

After watching a terrific movie last night with my daughter, https://www.thebusinessof.life/the-business-of-birth-control , I’ve been thinking about my own reproductive life and birth control use.

I’ve been lucky. When I was taking the Pill, starting in 1967, the dosage of hormones was 100 times greater than in today’s products. My doctor never mentioned side effects and I didn’t have any that I can remember.  I enjoyed sex whenever I wanted, without fear of pregnancy. These were golden years, those between the Pill and the emergence of herpes and HIV. I had a good time, and learned a lot, including the knowledge that one-night stands were worthless.

In the 1970s, the IUD was invented and I got a Dalkon Shield, again without a mention of any risk. Again, I was lucky, perhaps because I was in a monogamous marriage, and not exposed to the variety of germs that came with more than one partner. These germs would walk up the little string that hung out of the cervix, acting like a ladder to the reproductive tract. My girlfriend  developed a severe reproductive tract infection that led to a total hysterectomy when she was only 25. She lost any chance to have babies, and was sent into premature menopause, as her ovaries were removed. She was awarded a lot of money in damages from the class action suit; she would have preferred to have a baby.

About 200,000 women suffered as a result of the Dalkon Shield being sold to the public before enough information about its impact had been collected.”. . .  follow up averaged only four and a half months across 640 women. Over time, reports of high levels of pelvic inflammatory disease began to surface but the company was slow to act. It became clear that both the safety and efficacy of the Dalkon Shield had been overstated beyond the supporting evidence.”  https://blogs.bmj.com/bmjsrh/2019/05/27/medical-devices-and-the-legacy-of-the-dalkon-shield-the-struggle-for-evidence-based-contraception/   Seems like folks are in such a rush to earn money that devices get sold before all the information has been analyzed.

There were still many contraceptive choices throughout the late 1970s and1980s. I always enjoyed going to Planned Parenthood, where my concerns and questions were taken seriously, and all my choices explored. For a while,  I had a Lippes Loop, another IUD, that was okay for a while. After a few years,  the pain I felt during my period became intolerable, as my body was trying to expel the IUD along with my uterine lining. I had the IUD removed, and got a diaphragm.

Diaphragms are complicated and messy; I remember when the spring would twist away from my fingers and fling contraceptive jelly all over me. The only way for me to use the diaphragm easily was to have my partner insert it. This was fun. However, the diaphragm had to stay in for hours after one session, and if intercourse was repeated, more jelly had to be inserted. The jelly tasted awful, and had a numbing quality. Not an optimal method, and still better than nothing.

From the beginning of my reproductive life, I learned that contraception was totally my responsibility. I never expected my sexual partner to take any role to prevent pregnancy. Was this an artifact of the times, or a function of my own lack of self-esteem, or my own need to have total control and not rely on anyone else? Looking back, I feel that all these reasons were true.

In the early 80s, I started a new relationship, and Jon suggested the natural family planning method, using basal body temperature and cervical mucous to identify the fertile days.  It took cooperation with my partner, and several months to get enough baseline information for me to know when I was ripe. Working together to use a method that involved both of us felt good, and it worked.

I was surprised that my second husband wanted to learn about contraception, and was helpful to me as we learned about the workings of my body. What a concept: shared responsibility!  I wish that all young people could learn about this way to make decisions in a relationship.

I started working as a nurse in hospital maternity wards in the 1990s and saw how contraception was managed by many OB/GYNs. Usually, the doctor would come to the mother’s bedside on the day of hospital discharge and say, “You don’t want to get pregnant again, do you?” After having given birth just a day or two ago, no one ever feels up to going through pregnancy, labor and delivery again; so she would say, “No.” The doctor’s response would be, “Okay, here’s your Shot” and write the order to give an injection of Depot-Provera, also known as DMPA, with no discussion of side effects or risks, or impact on lactation.  As a good nurse, I never questioned this care, and participated in it.

For a long time, doula colleagues have been telling me that contraceptive practices have become overtly racialized. White women with private health insurance go home from the hospital without any discussion about contraception, whereas adolescent, Black, Brown, Native American, Asian, poor and Immigrant mothers are repeatedly asked about birth control until they agree to something. (When I say repeatedly, I mean as many as 8 times, until a mother yields.)

Since Medicaid has now become the dominant source of funding for Long Acting Reversible Contraception in the US. https://www.guttmacher.org/article/2016/07/cms-provides-new-clarity-family-planning-under-medicaid     LARC is pushed with only brief (or no) lengthy discussion. IUDs are put in within 10 minutes of delivery of the placenta.  ACOG states, ” Expulsion rates for immediate postpartum IUD insertions are higher than for interval or postabortion insertions, vary by study, and may be as high as 10–27%”.  With such high rates of expulsion, one wonders why bother? Perhaps because hospitals and providers can bill for the service, no matter what?  https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/08/immediate-postpartum-long-acting-reversible-contraception

Services follow reimbursement. This quote from the Guttmacher Article cited above explains. “Those efforts have included unbundling payment for LARCs from other labor and delivery services, and allowing providers to bill for both an office visit and a device insertion on the same day.”  Whee: the mother comes to visit once and her insurance can be billed twice. What could be better?

Hospitals need revenue, and giving LARC (IUDs, Nexplanon and Depot-Provera) generates income, so more women are coming home with LARC in place, even though: “Among (58 ) women who initiated breastfeeding and received DMPA in the immediate postpartum period, the majority (72.4%) did not plan to use this contraceptive method. (The Discordance Between Planned Use and Actual Receipt of Immediate Postpartum Depot Medroxyprogesterone Among Low-Income Women Brownell et al Breastfeeding Medicine 2014; 9(6):10-18)

As LARC dominates hospital practice, other contraceptive methods are rarely discussed. The Lactational Amenorrhea Method when followed according to the evidence, offers 98-99% protection from pregnancy. When I wanted to include information about this method for an educational film made by the Philadelphia Department of Public Health in the late 1990s, a lovely discussion about LAM with a mother attending a postpartum clinic was cut out of the final product. I was told, “women don’t breastfeed well enough to talk about this method.” An assumption is made that a mother can’t or won’t be able to discuss her own body and make the right choice; the truth is that the medical system does not have the time for in-depth discussions. I wonder how many women would breastfeed exclusively for longer if they knew that they would be protected from pregnancy for up to 6 months, as long as they don’t have a period.

The Global Health Media Project is an organization that makes an amazing series of educational videos in many languages, designed to serve “underserved populations in Africa and Asia.”  Their breastfeeding videos are fabulous. Their videos about contraception speak only about LARC:  Depot, the implant and the IUD. How contraception is presented in US hospitals is being shared with the world.

The Center for Medicaid and Medicare Services (CMS) has relationships with the pharmaceutical industry: “CMS also touted collaborations with pharmaceutical manufacturers to address the up-front costs of keeping expensive devices in stock. It even suggested that states might seek special permission from CMS to purchase contraceptive supplies up-front for providers. (Guttmacher, op. cit above)  As hormonal contraception requires a prescription, both doctors and industry make money. Other methods are cheaper, and therefore, less valuable in our capitalistic system where profit is more important than health.

When industry links with factory obstetrics, what chance do women have to explore their choices?

Watching the Business of Birth Control with my daughter last night filled me with a sense of hope as I learned about contraceptive apps, and saw young women learning about their bodies in a way that was considered too far out 50 years ago.  My daughter uses a basal body thermometer and an app  to track her fertile days; during the ripe time her husband uses condoms. I love that she’s not filling her body with risky chemicals, and that  she and her husband are sharing the responsibility.

Controlling one’s fertility is an essential part of life. The freedom to choose when to have children releases everyone from the inevitability of conception that imprisoned my grandmothers. I am grateful for having contraception in my life. I wish that everyone has the opportunity to choose their own methods, and that these methods are proven safe by evidence collected by objective observers, and analyzed.

Hormonal methods have their appeal: always there, nothing to insert or to lose, freedom from male partner resistance, and high reliability. However, they also change how the body functions, and have a powerful, and potentially damaging, impact on physiology, including moods and personality.

For example, the product insert for Depot-Provera says that these conditions must be explored before using the product:

• a family history of cancer of the breast
• an abnormal mammogram (breast X-ray), fibrocystic breast disease, breast nodules or lumps, or bleeding from your nipples
• kidney disease;  irregular or scanty menstrual periods
• high blood pressure
• migraine headaches
• asthma
• epilepsy (convulsions or seizures)
• diabetes or a family history of diabetes
• a history of depression

https://www.accessdata.fda.gov/drugsatfda_docs/label/2003/20246scs019_Depo-provera_lbl.pdf

While hormonal birth control is common, discussion of risks and side effects is not. The product inserts are lengthy and written in medical language using a tiny font that is not easy or encouraging to read, much less understand. These inserts provide legal protection for the manufacturer and need to be written at a 3rd grade reading level.

I am not in favor of coercion, nor of methods used that pose a risk to the health and well-being of the user, nor of using contraception as a method of eugenics.

Contraception should be as safe as possible, and give women the freedom to live the life they chose, while ensuring that every baby born is  planned for.