A major development in women’s health is the increasing popularity of long-acting reversible contraceptives (LARCs), which refer to intrauterine devices (IUDs) and contraceptive implants.¹ These are now among the most commonly used birth control methods, with their use having rapidly increased in the last few decades, from a rate of 2.4% in 2002 to more than 11% of women in 2012.² LARCs are an attractive birth control option as a highly effective way to prevent pregnancy regardless of age, parity, and body mass index.³ Qualities of appeal from a patient perspective may include their cost effectiveness, the lack of continual efforts needed to ensure efficacy thereby reducing contraceptive failures, and the rapid return to fertility if desired after removal.^1,2

From a public health perspective, increased LARC utilization has been proposed as an effective intervention to reduce the rates of unintended pregnancy and abortion.³ In fact, as a result of increasing LARC use and other factors, the rates of both abortion and unintended pregnancies have declined, although unintentional pregnancies remain high at 45%.^2,4 As a result, some healthcare providers may demonstrate enthusiasm in their recommendations of LARCs as an effective birth control option. Although LARC users report a higher rate of satisfaction compared to other contraception methods, 10% to 20% desire discontinuation within the first year of use.⁵ Once this personal decision has been made, women are citing multiple hurdles for removal.^1,5,6 These documented barriers to LARC removal stand as threats to reproductive autonomy for women.

Patient obstacles to reproductive autonomy

Analyses conducted based on interviews and posts from online forums show several obstacles to LARC removal, many caused by healthcare provider hesitancy and poor healthcare access.^1,5,6 The most common reasons for LARC users to consider discontinuation are side effects, women often citing multiple concerns at once.⁶ Some report cramping and bleeding that were unexpectedly severe, but most complain of systemic symptoms affecting quality of life such as weight gain and fatigue.⁶ Women also seek LARC discontinuation out of a desire for pregnancy.⁶ Once deciding that discontinuing their long-acting contraceptive is best for them, women find that removal is not as supported as insertion.¹ Many report that their healthcare providers minimize side effects at the time of birth control counseling.¹ At the same time, once reporting bothersome effects, women are confronted by provider reluctance or refusal to discontinue the LARC even after multiple visits.⁶ Women also report challenges regarding appointment availability and high costs for the removal procedure.⁶ The weeks-or months-long wait has led some to resort to self-removal of IUDs.^5,6 In fact, a simple internet search will reveal 15 years’ worth of personal perspectives and how-to videos, including those which describe step-by-step how to self-remove IUDs at home.⁶

The majority of women trust their healthcare providers as experienced sources of information and care regarding birth control methods.¹ At the same time, many women believe that providers do not take into account their own preferences for contraception selection and that their concerns are minimized once they desire LARC removal.¹ Concerning impacts of the inherent power differentials that exist between healthcare providers and women have the potential to create oppression, especially when provider preferences are held above patient values and desires. Autonomy is a pillar of healthcare that must be upheld. Providers may help give women the autonomy to choose LARCs as a way to control if or when they have children or for varied other reasons. Providers must remember to uphold autonomy by removing such devices once a person decides they no longer want them.

Improving contraceptive counseling

Positive conversations during clinical encounters have the power to promote patient satisfaction with the provider–patient relationship, to improve patient care outcomes, and to reduce health disparities.⁷ Accordingly, the first solution to the problem of LARC removal barriers is to improve the conversations taking place between providers and patients surrounding contraceptive options, including LARCs. Enhanced contraceptive counseling will help ensure patient-centered care and patient-informed decision making. Healthcare providers must provide adequate education on (not minimizing) the most common and concerning side effects as well as advantages and disadvantages of all birth control options a patient may wish to consider. Sufficient education will better prepare women for anticipated effects and experiences, or otherwise help them to make informed decisions about the choice of these methods.

Avoiding negotiation tactics and frustration

Persuasive tactics are employed by some healthcare providers attempting to offer reassurance to patients who first express concern for side effects. One study found that most providers use negotiation as an initial strategy to encourage continued use of LARCs^.7 This involves imploring patients to wait an arbitrary period of time and then reassess the symptom at a later date, regardless of the specific complaint (except in the case of possible serious complication).⁷ If the side effect were an expected one, such as bleeding, a patient would in theory not ask providers for “early” removal if adequate education had been given prior to the choice of LARC. In the setting of informed decision making leading to the contraceptive choice, patient concerns should be validated and patients should be provided continued agency over their reproductive options. Negotiation should be considered a form of coercion and a way to assert provider authority, ultimately a paternalistic tactic that threatens patient autonomy, especially if a patient does not feel empowered enough to insist on a preference or value.⁷ Putting off removal to a later date also increases inconvenience to patients, who may not easily have access to a future appointment.

Healthcare providers may additionally feel a sense of frustration regarding patient contraceptive decisions, including a patient’s wish for LARC removal, believing this may not be in a patient’s best interest.⁷ Although patient wellbeing should undoubtedly remain a priority, provider values and opinions must never supersede patient decision making that reflects their own perspectives and goals for personal health and life.

System change and self-removal of IUDs

Next, system change to increase the availability of contraceptive appointments and decrease costs for LARC removal procedures, if possible, may improve contraceptive management and care access. Clinical leaders must consider how they may or may not be adequately serving their community’s contraceptive care needs. Setting aside or increasing the availability of contraceptive management appointments, such as providing established walk-in hours, may remove a major existing barrier to current patients. Healthcare providers also should assess the charge master for their practice and consider the set price for removal of LARCs. The cost may not significantly affect those with insurance, but high costs for the simple removal procedure of an IUD, for example, can create a major barrier to self-pay patients, including adolescents and other groups who frequently face access problems.

Healthcare providers also may consider being open to discussing self-removal of IUDs. Most first self-removal attempts are not successful.⁸ Women are currently estimated to be successful at self-removal around 20% of the time.⁵ The majority also prefer that their providers remove their IUDs.⁶ However, analysis of internet forums shows overwhelmingly positive self-removal experiences, and a wealth of inexpert but true-to-life information regarding advice on safe and efficient removal at home.⁸ More research regarding self-removal of IUDs is warranted, but anticipatory guidance on performing this procedure at home may prove to be a future viable, even common, option for LARC discontinuation.

Final thoughts on LARC removal

A final recommendation is a simple one: educate, believe, and empower women. Adequate education on contraceptive options and their side effects will create more informed patients who, empowered with information, will make the best decisions for their reproductive health. Next, active listening will ensure patients feel heard and respected, even increasing patient perceptions of care quality. There are many individual side effects that can be reported causing discomfort or distress in women using LARCs. Healthcare providers must be willing to consider and acknowledge these perceived side effects, and even still, be willing to remove LARCs if it is the patient’s desire in order to promote reproductive autonomy. These steps will further solidify patient–provider care partnerships toward better delivery of women’s healthcare.

Baily M. Weskamp is a WHNP student at Georgetown University School of Nursing & Health Studies, Washington, DC. Gina M. Fullbright is adjunct faculty at Georgetown University School of Nursing & Health Studies. The authors have no actual or potential conflicts of interest in relation to the contents of this article.

References

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