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Why Handing Out Birth Control Will Not Help Women Manage Fertility The Way They Want


This Christmas season, my mind is on infertility. Over the last few years, Delaware has launched a partnership with an organization called Upstream USA to increase women’s access to contraceptives, especially long-acting reversible contraceptives (LARCs). The New York Times has reported on this partnership, saying it could reduce poverty in Delaware, and that Upstream provided the initial funding for the program.

LARCs have been controversial with some conservatives because some early LARCs, especially some intrauterine devices or IUDs, functioned not by preventing conception, but by preventing implantation: something most pro-life people consider to be an abortion. Most LARCs used today are of a different variety, and probably work primarily by preventing conception, like other forms of birth control. However, this “probably” still worries some conservatives.

That said, the striking thing about the report is actually not any controversy about LARCs, but what it reveals about the poor state of medical care for women in Delaware and elsewhere. As part of the new protocol for reproductive care, Upstream has induced Delaware to adopt a new diagnostic question doctors must ask for medical purposes: “Do you want to become pregnant in the next year?”

If they answer “yes,” they’re given some information about prenatal care — which is a bit odd, since prenatal care is not the same thing as helping someone become pregnant. If they answer “no,” they’re immediately directed towards birth control, and encouraged to consider LARCs.

This protocol for care is absurd for numerous reasons. On the most basic level, it is absurd that Delaware never cared to ask women about their family goals until an outside interest group which, according to its 990s, has spent hundreds of thousands of dollars on lobbying campaigns, pushed them to promote technologies which reduce childbearing.

Suddenly, given the opportunity to reduce childbearing, Delaware is very interested to hear what women want. This, despite the fact that numerous surveys have demonstrated that the average woman ends up having fewer children than she says she wants. How convenient that Delaware now cares to ask women what they want.

Don’t Impose Significant Medical Interventions On a Lark

But on a higher level, Delaware and Upstream are encouraging a strange standard of care. LARCs are, by definition, “long-acting.” And while they are indeed reversible, it can take two to 12 months from removal for the effects of a LARC to fully wear off.

The problem is that a woman who does not wish to become pregnant in the next year on, say, January, may have a change of heart in March, but now there’s a LARC in. The time period of interest doctors should be asking about for a LARC is not the time period it is in place, but the time period it is in place plus however long it will take the woman to become pregnant after removal. Otherwise, LARCs will delay a substantial amount of desired fertility as well.

This problem represents the key issue: information. Women should have affordable, convenient access to birth control, including LARCs, and they should be provided information about them. Delaware has greatly increased access to LARCs without actually providing women a relevant increase in information about fertility.

About half of births are unplanned. If Upstream achieves its goal and eliminates all unplanned pregnancies, Delaware’s birth rate will fall by about half. In this world of 0.9 children born per woman on average, Delaware’s population will collapse and the state willexperience a durable economic contraction.

The assumption here is that women who get a LARC will “replace” unplanned births later. But that may not happen! Most unplanned births are not unwanted, simply mistimed. But a LARC is a poor solution to a mistimed pregnancy: getting a LARC as a solution to having a kid a year or two earlier than planned is not the right use case! But by providing a long-term solution (LARCs) to a largely short-term problem (birth timing and spacing), it is likely that the birth planning problem will be resolved at least in part through fewer, not just later births. This is what we observe happening nationally, as delayed fertility is turning into foregone fertility.

More to the point, many unplanned births are in fact desired. I was an unplanned birth, and my conception massively inconvenienced my parents, who were living abroad. My birth was a serious disruption to both of their careers. It probably reduced their long-term earnings, truth be told, especially my father’s, whose first sabbatical as a professor was irrevocably altered.

What should be made of this? Well, simply put, “unplanned” births aren’t the problem: it’s unwanted births. Delaware asks women about wantedness, not plannedness, but Upstream’s goal is clearly about planning. But if you had asked my wife and I if we “wanted” to get pregnant in the next year, say, two years ago, we would have said, “Not sure? Maybe, if that’s what God has in store for us.” How is a doctor in Delaware to respond to that?

We clearly weren’t planning to have a baby. But we weren’t planning not to. Millions of Americans around the country adopt the “see what happens” method of family non-planning. That should not be stigmatized, and medical practitioners should not be trained to pathologize ambiguity in women’s fertility intentions, or to treat a preference for not having a child just yet as necessarily a reason to encourage a long-lasting intervention.

Americans Are Woefully Uninformed about Fertility

The deeper problem, however, goes back to the first issue I noted: Delaware never cared to ask women about fertility until now. If they had asked women about fertility, do you know what they would have found?

Unscientific folklore abounds! People believe absurd things about fertility, even very educated people! Did you know that most Americans think biological fertility decline doesn’t start until your thirties, and many people think not until your forties? That’s an insane belief! Of course fertility declines before your forties! In reality, most people reach peak biological fertility in their mid-twenties.

It turns out, people do not understand how babies are made. Academic research confirms that people really aren’t that far from believing in storks.

Surveys of people in Portugal showed very poor understanding of when fertility declines and how effective reproductive technology is at boosting odds of conception. The study concluded that general medical practices should do better at informing women about fertility. Only 18 percent of women surveyed had ever discussed their fertility with their doctor.

Danish men are in even worse shape: they basically had never even heard of male infertility, and routinely expected to be making lots of babies when their wives were in their forties. Finnish university students believe, on average, that female fertility is about stable until age 45. American women rate themselves as being knowledgeable about fertility, but then score a less than 50 percent on a basic quiz of fertility knowledge. American men are even worse.

A large international study of many countries found that around the world, peoples’ scores on fertility quizzes are basically a coin toss. But one group of people is systematically better-informed about fertility. You know who? People with a history of infertility. You don’t know what you’ve got until it’s gone. The way most people get educated about fertility is by learning that it’s too late for them. People with better knowledge of fertility also tended to be more willing to consider reproductive technology as an aid, or lifestyle changes to enhance childbearing odds.

But what if, say, a doctor were to inform women about some very basic, scientific fertility facts? Would it make any difference? It probably would! A randomized controlled study in Canada found that informing women about fertility-related information caused them to state a desire to have more children at a younger age. Another Canadian study showed the same with a slightly bigger sample size. A study in Australia showed the same thing again: briefly informing women about fertility causes them to express a desire to have kids sooner.

Plagued by Fertility Myths

In other words, one reason women express a desire to delay childbearing is because our society is full of unscientific myths about fertility. It takes longer to get pregnant, miscarriage is more common, and fertility declines sooner than most young people realize. Reproductive technology has a lower success rate, especially for older women, than its advertising might suggest.

In other words, much as we should stop lying to young people about the lack of trade-off between work and family, we should stop lying to young people that there’s always more time to have kids. There isn’t more time, especially if you want to have three, four, or five kids. You don’t know your biological fertility, or you and your partner’s interfertility (biological fertility is complex: sometimes two people with normal reproductive systems nonetheless cannot conceive together easily, even if they could conceive easily with some other partner).

Male and female biological fertility begins to enter significant decline sometime in your later twenties to mid-thirties, and even if you do conceive, miscarriage claims perhaps as many as half of conceptions. When you add in the difficulty of finding a suitable partner, getting stable health insurance, avoiding serious economic strains — folks, there’s no time to waste.

We would do well to remember the difficulties facing disadvantaged women, and help them, and all women, steward their fertility fruitfully: by avoiding truly unwanted conceptions, but also by achieving desired ones. Delaware’s strategy is all about avoidance. It isn’t about empowering women, it’s about suppressing births.

We need a serious social movement that embraces both sides of this question, recognizing parents in all the complexities of their desires, fears, and hopes: a movement concerned to help a single mom complete her degree, help a teenage girl avoid an unwanted pregnancy, and help a working-class family with four kids balance the budget.

But also around Christmas time, we remember that although Mary’s conception was unplanned, it was not unwanted. Rather it was the fulfillment of the desire of every nation. Things we didn’t plan are not by nature of their unplanned-ness bad. So maybe it wasn’t your plan for what to do over Christmas, and maybe you’ve been telling yourself you can wait a few more years before trying, but consider talking to your spouse about a different kind of Christmas gift: it’s a great season to make a baby.