Reclaiming a Crisis: Backline is Working to Open the First All Options Pregnancy Center

By: Catrina Otonoga

If you dare utter the initials CPC in a room full of pro-choicers in a positive light, you better be prepared for some backlash. Talking about crisis pregnancy centers as a positive institution among reproductive justice, reproductive rights, and reproductive health advocates elicits a room full of negative reactions.

CPCs manipulate women at a vulnerable time in their lives.

CPCs don’t educate people about all their options.

CPCs hurt women.

So imagine my surprise when I was talking to Parker Dockray, Executive Director of Backline, about how she wants to emulate the crisis pregnancy center model.

“The model that CPCs have developed is valuable,” said Dockray, “but pregnancy  centers should not be deceptive.”

Dockray and the board and staff at Backline have decided to embark on an unparalleled mission, to create the first all options crisis pregnancy center. Crisis pregnancy centers are some of the most available institutions out there for women who are unsure about their pregnancy. Indiana has over 80, and they are one of 34 states that funnel money directly to crisis pregnancy centers. But they are full of misinformation and missing information.

However, as Dockray told me, CPCs often appear to meet the needs of women, even when they clearly don’t. Backline wants to reclaim the CPC model and create a brick and mortar place for the people of Indiana to turn to for support and community.

For the last 10 years, Backline has been answering the phone and offering support to people looking for options and judgment free counseling surrounding pregnancy. The Backline Talkline answers hundreds of questions each month about pregnancy options, parenting, abortion, adoption, pregnancy loss, miscarriage and other reproductive health topics. While the phone offers confidentiality, a new model could provide women with tangible support.

“The prochoice movement is not always great about visibly supporting parents,” said Dockray. Dockray hopes Backline’s new initiative will become a tangible place to demonstrate support for women across all options. Backline wants to create a place for women and their partners to receive counseling on abortion, adoption, and carrying their pregnancy to term as well as carrying diapers and other items for people to support their partners.

Opening the center in Indiana strikes a cord in a new way. The center will find its home in the middle of a red state, in a college town, surrounded by fields and conservative ideals. Reproductive rights, health and justice organizations are too siloed from each other, with each sticking to their own areas without much overlap or conversation. Backline’s All Options Pregnancy Center would bring these together under one roof, without agenda or pretense. Instead of being siloed, they are setting up shop amidst the silos in America’s Midwest heartland.

Bloomington is a town divided, one side of town is home to Hannah House Crisis Pregnancy Center, and the other is home to Planned Parenthood of Bloomington. Backline would create a middle ground, a place for women and their partners to go for real information. At a time when the middle ground seems like an impossibility in American politics, the Backline All Options Pregnancy Center will be an oasis. An oasis of information, moderatism, and choice, at a time and in a place where that hasn’t existed in a long time.

Welcome to the Midwest, Backline. If you want to help Backline build some walls, knock down some silos, and give people a place do go; click here if you’d like to donate, and click here if you live in Indiana and would like to join in.

What’s new in contraceptive technology?

Lots of great new contraceptive options are coming your way soon if you’re in the United States.  You may have already heard about Skyla, but do you know about Twirla and Cyclofem?  Read on and learn.

Skyla

Skyla (or the levonorgestrel 14 mcg IUD, or LNG-14) recently was approved by the FDA and has received a fair amount of attention.  It is now available from some providers and may be an excellent choice for some women.  The LNG-14 has three claims to fame: its smaller size (and, as a result, smaller inserter), its lower dose of progesterone, and its official approval for use by women who have never been pregnant.

First off, the smaller size: in the grand scheme of things, we’re talking about only a very tiny difference (the IUD itself is 1.1 by 1.2 inches, compared with Mirena’s 1.3 by 1.3 inches, while the inserter is 0.04 inches smaller than Mirena’s; see this great article for more details).  However, that very small difference may in fact make insertion of the device less painful for some women, particularly women who have never been pregnant and may be more likely to have a tighter cervix.  Since the data have yet to be published, I can’t tell you for sure if insertion is indeed less uncomfortable than insertion of other IUDs; however, preliminary presentations of the data (such as here) have indicated that, for women who have never been pregnant, those who underwent insertion of Skyla had less discomfort than those who were assigned to Mirena. 

Skyla releases less progesterone than the Mirena (without losing any of its contraceptive efficacy) which for some women is a good thing, but for others might not be.  One of the features of Mirena that is most appreciated by some users is that almost everyone experiences lighter periods over time, and many women no longer have periods at all.  For some women, that’s fabulous, while others would rather keep seeing their period.  Women using Skyla will mostly have lighter periods, but fewer of them will have no period (though some will, and there is no way to know ahead of time what any individual’s reaction will be).  Although Mirena exposes users to a very low systemic dose of progesterone (a dose low enough that most don’t notice it), for women who are extremely sensitive to artificial hormones it can still be too much.  If you’re in this category but there are reasons why a progesterone-releasing IUD is a good option for you (such as heavy periods), Skyla may be an excellent option.

Finally, on Skyla’s approval for women who have never been pregnant.  This is great news, but really, it’s not news; women who have never been pregnant can safely use any IUD, regardless of what is on the packaging.  We’ve known this for years, and doctors use products and medicines off-label all the time.  There’s nothing wrong with off-label use as long as there is good evidence to show that your practice is safe.  Fortunately, we have decades of data that prove that women who have never been pregnant can safely use any kind of IUD they want.  So the labeling for women who’ve never been pregnant may be generating a lot of buzz, but it’s nothing new.  However, if there are pesky insurance companies out there that won’t pay for IUDs for women who’ve never been pregnant because the label says it’s not OK, this might help push them along, so it can’t be bad.

There’s a lot to love about Skyla.  The smaller size might make it easier and more comfortable to insert for some women, and the lower hormone dose might be beneficial in some cases.  Unfortunately, Skyla only lasts for 3 years (as opposed to 5 for Mirena and 12 or more for the copper-IUD).  For some women who don’t like the idea of something lasting a long time this may a good thing, but for many having to get a new one placed after 3 years could be a drag, as it means another doctor’s visit and potentially more costs.

Twirla

Twirla (also known as AG 200-15) is a new contraceptive patch that uses a combination of progesterone and estrogen, similar to Ortho-Evra.  This method is not yet FDA approved but will likely be approved in the next year.  Twirla has a few claims to fame: its lower estrogen dose and its novel adhesive.  As for the lower estrogen dose, as only a few papers have been published on Twirla thus far, I don’t know for sure if the lower estrogen dose in this patch compared with Ortho-Evra leads to fewer side effects, but it is quite likely it does, and we know that this patch is just as effective as Ortho-Evra.  

So if you’re very sensitive to hormones and want to use a patch, Twirla may turn out to be a great option, especially if the side effects you experience on birth control are related to estrogen (such as nausea, bloating, or headaches) and you have reasons to want to continue using an estrogen-containing method, such as maintaining regular periods or to improve acne.  The novel adhesive may be good news for loyal patch fans who are annoyed by the little bits of adhesive residue that sometimes seep out next to where the patch is applied, or for women who want to use the patch but are among the minority of women for whom it just won’t stay on for the whole week.

Cyclofem

Cyclofem (also known as depot medroxyprogesterone acetate 15 mg/estradiol cypionate 5 mg) is not actually a new contraceptive; rather, it’s a method that’s been around for a while and has never really taken off, either in the US or abroad.  Cyclofem is an injectable contraceptive that was briefly marketed in the US as Lunelle about a decade ago, but has not been available recently.  It is used in some other countries around the world.  It has a lower dose of the progesterone that is used in Depo-Provera, the three-monthly injectable, and unlike Depo-provera also has estrogen.  Cyclofem’s claims to fame: the only combined hormonal injectable method available; convenience of once-monthly dosing.

Although Depo-Provera, or DMPA, is not one of the most popular methods in the U.S., it has loyal followers.  Some of the pros of DMPA are that injections are required only every three months, with a very forgiving window period allowing you to get your shot a few weeks early (in case you’re heading off for vacation) or a few weeks late (up to 15 weeks since the prior injection – considering the busy lives many of us lead, the more likely scenario), and that most women stop having periods within 6 to 12 months of starting the method.  DMPA only includes progesterone; for women who want an injectable that also has an estrogen, Cyclofem could be useful.  Women using Cyclofem generally continue to have regular periods, but the big drawback is that injections have to occur every month.  There are some situations where Cyclofem could be extremely useful; for instance, someone who wants to use a combined hormonal method but can’t swallow pills or someone who requires absolute privacy regarding her use of contraceptives.

Unlike the other new methods I’ve described, it’s hard for me to believe this method will take off in the US context outside of some specialized settings, as the majority of women who can’t take pills will probably be well-served with either a contraceptive patch or ring, and women who need to use an “invisible” method will in most cases do very well with an IUD or a contraceptive implant.  Monthly visits to the doctor for injections are just not practical for most women in a US context.  Despite my pessimism, I do hope that Cyclofem finds its niche; more choices are always better, and there will always be women who find that a given method works very well for them.

What about plans for the next five and ten years?  There are lots of great products in the works, from a much lower-cost generic version of the Mirena IUD being developed by Medicines360 (this could really be a game changer for women in many low-income countries; not only is the levonorgestrel IUD a great contraceptive method, but it also is a first-line treatment for many other gynecological conditions that are currently treated with surgery in settings where it is unavailable) to a contraceptive vaginal ring that can be used for a whole year.  A new female condom that may be easier to use and more comfortable is also in the works.

Acknowledgments: This post was inspired by a great webinar from the Association of Reproductive Health Professionals.

Diagnosis: Female?

Lots of people are talking about the decision on the part of HHS that all forms of contraception be covered for all insured men and women for “free” as basic preventive services under health reform. This decision came not a minute too soon. Recently I found myself having to call in a prior authorization for birth control for one of my patients. At first I figured it was just that the insurance didn’t pay for the birth control patch, Ortho-Evra, but did pay for other methods. However, it turned out to be more complicated. The entire conversation took a half hour and went more or less as follows:

Me: This is Dr. Pro Choice. I’m calling to get a prior authorization for ortho-evra for my patient.

Customer Service Associate: OK, let me look into that for you…(5 minutes of terrible muzak later) I’m showing we don’t cover that medication.

Me: Right, that’s why I’m calling. Can you tell me why you don’t cover that medication?

CSA: Let me look into that for you… (5 minutes of even worse muzak later) We don’t cover any contraceptive methods.

Me: What? Are you sure?

CSA: Yes Ma’am, this plan that your patient signed up for does not cover contraceptive methods.

Me: (after a moment of disbelief) So how can I get this for my patient? She can’t afford it on her own. She has Medicaid.

CSA: You can make an application.

Me: Great, let’s do that.

CSA: What is the diagnosis?

Me: Diagnosis?

CSA: Yes, what is the diagnosis?

Me: (long pause) Female?

CSA: That is not an accepted diagnosis

Me: Human? Able to get pregnant? Sexually active?

CSA: Those are not accepted either.

Me: Umm, OK, menorrhagia [not the real reason but a ‘real’ diagnosis].

[1 minute on hold]

CSA: Your request has been approved.

I wish I could say I made this up, but it happened just a few weeks before this decision came from HHS. There IS no diagnosis code justifying contraception as a way to avoid pregnancy, because diagnosis codes are built around illness. Avoiding pregnancy usually isn’t about already being sick, it’s about preventing something from happening. So birth control clearly belongs in the list of preventive services.

I fear politics will get in the way of the HHS ruling that all contraceptive services be covered free of charge under all insurers starting next year, but if not, women with private or public insurance will not have to pay for their birth control. This is a huge step for all women, and a small step for doctors like me who will no longer have to have conversations such as the one above.

Free Birth Control?! Implausible. Well, maybe.

This post is part of the Birth Control Blog Carnival sponsored by the National Women’s Law Center and Planned Parenthood.

Birth control should be free for women. We’ve all heard that every dollar spent on family planning saves four. Economically, it is a no brainer. Politically, it becomes a bit more complicated as, heaven forbid, a politician endorses happy and safe sex lives. Personally, I would like stop spending 35 bucks a month on pills. That money could easily be reallocated to Chinese food or shoes, still fueling our ailing economy. The problem is there are many other players between me and my pink round pill pack. In fact, there are so many that I’m not going to list them all here (think insurers, pharmaceutical firms, pharmacists, pharmacies, etc). So how can we make birth control free?

Just on Tuesday an advisory panel from the Institute of Medicine (IOM) recommended eight women’s health preventive services be added to the government mandated list of services provided and paid for by health insurance companies at no cost to patients. Included in the list was the following: “a fuller range of contraceptive education, counseling, methods, and services so that women can better avoid unwanted pregnancies and space their pregnancies to promote optimal birth outcomes.”

So now birth control will be “free” (if by free you mean still paying an arm and a leg to health insurers who will end-up economically benefiting from paying for your said “free” birth control)? Right? Well, not quite. IOM made the recommendation to yet another government body, Health and Human Services (HHS). The big kahuna if you will. Now HHS needs to decide if these recommendations will actually be included on the no cost consumer list.

All said this is probably not going to change overnight. If it does, Chinese takeout for all! But in the interim, as a public health nerd, I have to ponder if free birth control is even a good idea. Hear me out.

I want you to imagine two shopping bags. One full of free swag from an event you paid to attend, the other a brand new purchase of totally your own choosing. Think about the contents of each, number of items, colors, shapes, perhaps even smells. Okay. Now you only get to keep one, which one do you take?

The purchased one, right? Unless of course your free swag bag is from the Oscars, I imagine it contains flyers, shampoo samples, and, if you’re lucky, a few granola bars. I cannot imagine getting a new pair of shoes or hot General Tso’s chicken for free, and I’m pretty sure neither can you. That’s the problem. Although birth control should be free for women and society would benefit on a multitude of levels from it being so, women might not take the same stock in their birth control if it’s handed to them. It might not seem as valuable, and then possibly effective, or useful, and that is exactly what we want to try and avoid.

Not convinced? Neither am I. Most women, most of the time, don’t want babies. I watched a documentary this week where a woman walked three hours in the blistering African sun just to see if contraception had arrived at her “local” clinic. Women everywhere really want this stuff. They will go to great lengths to get it whether it is walking miles or listening to Michael Bolton on hold for three hours. What really sold me on women’s value of even free birth control was asking friends this question: what is the best part about going to the gyno? I know, I know, it is all awful. I too have seen the Vagina Monologues 12 times. But there is one good thing. Free samples! Everyone uses those free birth control samples and they get so excited. It’s a little surprise win for suffering the fate of the duck lips. Everyone who I talked to, in my very limited and skewed but loving sample, agreed that they actually use them. That in fact they end up using them more correctly and consistently because they are just sitting around their apartment and there is no need to go to the pharmacy once a month (but that is another battle altogether).

So women use free birth control. We’ve seen it in action. Maybe getting it for “free” from insurers would *gasp* encourage women to use birth control more consistently and correctly. Maybe that could make for happier, healthier families, women and sex lives. Maybe.

IUD insertion immediately after abortion: Time to break down the barriers

Although women get abortions for many reasons, the majority of women choosing abortion do so because they got pregnant when they didn’t want to be. It stands to reason that at the time of the abortion is a perfect time to help women start using highly effective contraceptives. One of the most effective methods, the IUD, is an ideal choice for women without plans to become pregnant in the short-term because once inserted it is effective for 7-12 years (depending on which IUD is chosen) and requires no ongoing maintenance, unlike other methods which require visits to clinics and remembering to take a pill daily, change a patch or ring, or get a shot every 3 months. All of this ongoing maintenance requires time and money.

So the IUD offers women a simple, long-term, easily reversible contraception that is as effective as tubal ligation (having one’s tubes “tied”). It is also the most cost-effective method available (when used long-term; the costs over the first few years are higher than other methods). So what’s the hold-up? Why do only 5.5% of Americans use IUDs?

Women do not get the most effective contraceptive care for the same reasons that many Americans don’t get the most effective health care in general. We have a system built on a fee-for-service model that relies on short-term membership in private insurance plans, which disincentivizes investment in preventive, cost-effective care that has up-front costs. We have a system that bills per service rather than for caring for a patient. We have a system in which pharmaceutical and device companies raise their prices significantly with impunity. (We also have a culture that systematically misinforms teens and adults alike about sex and contraception, but you can read about that here, here, and here).

Many women with private insurance find that their insurance does not cover one of the most effective, and the most cost-effective, methods available. The IUD itself can cost over $800, with the insertion fee from the physician easily bringing the cost to $1200 or more. Because many young people will change from insurer to insurer as they change jobs, the companies generally do not want to invest that kind of money into pregnancy prevention for their members. What makes sense for the individual, or even our society as a whole, often does not make sense for a profit-driven insurance company.

Billing is another barrier. Unfortunately, all clinics providing reproductive health care must pay attention to their bottom line. They can’t provide the vital services they offer if they don’t stay afloat. So unnecessary requirements, such as lack of reimbursement from insurance companies for IUD insertion done on the same day as an abortion, substantially hamper access for women. The result has often been that women have to wait until their follow-up appointment to get their IUD inserted, meaning they have to go through another procedure (when the IUD could easily have been inserted in less than 1 minute if done immediately after the abortion) and also have to make it to a follow-up appointment, which means more time off from work, more money for child care and transportation, and often more money for the visit to the clinic.

Barriers within the medical system also get in the way; some physicians believe that inserting an IUD immediately after abortion is more likely to cause complications and more likely to self-expulse (or fall out).

Because of these barriers, many women who want to use an IUD for contraception after an abortion are leaving without one. Although they are given follow-up appointments and theoretically should as a result have good access to IUDs, the fact is that many women are slipping through the cracks.

Fortunately, a new study shows that IUD insertion immediately after an abortion is safe and effective, and most importantly prevents repeat unintended pregnancy. 575 women who wanted an IUD after their abortion were randomly assigned to two groups: one group that had the IUD inserted immediately while the other was given a follow-up appointment for the IUD two to six weeks after the abortion. Not surprisingly based on prior studies, the group that had the IUD inserted immediately after the abortion had a slightly higher expulsion rate (5% vs. 2.7%) than the delayed insertion group. Though this might sound like an argument against immediate insertion of IUDs after abortion, what’s actually important is how the individual woman is affected. Despite this higher expulsion rate, NONE of the women in the immediate insertion group were pregnant within six months, as opposed to FIVE in the delayed insertion group. All of those pregnancies occurred among the 29% of women who never managed to get their IUD after their abortion.

Bottom line: immediate IUD insertion after abortion is safe, effective, saves money, and most importantly, prevents unintended pregnancy! I hope that policy-makers and doctors will take note of this study and take action to break down the medical, policy, insurance, and financial barriers that keep women from getting the best care possible.

Male Birth Control

It is something feminists, male and female, have been waiting for for a long time: male birth control. The pharmaceutical industry, more interested in male erections has ignored our pleas. Well an Indian man has come up with a very promising birth control for men.

Basically, a procedure very similar to a vasectomy is performed but instead of snipping the vas deferens, a polymer compound is injected into the tube.  According to the developers of the method, the compound interferes with the spermatic cell membranes, rendering them incapable of egg fertilizations. Sperm production and male hormones are not affected.  In clinical trials thus far, the method is reported to be 100% effective. There are no reported side effects and not one woman has been impregnated by a treated man.  The developers also report that the method may be reversible with a repeat injection, though this data has not yet been published.  The article suggests that it is about 2 years away from approval in India, although it may be years before rigorous clinical trials are initiated in Europe and North America.

I could go on a rant about how it’s about damn time men were able to share the burden of avoiding pregnancy with women, because it certainly is. Or perhaps the likelihood that insurance companies, and heck the US government, will fund this while women are left to pay for their own birth control, which is certainly a possibility. But what I am excited about is the possibility that this could reduce the number of unwanted pregnancies.

Couples now don’t have to rely on a woman’s birth control or condoms. Couples who want to be doubly sure can have the man treated and then they won’t have to worry about broken condoms or a missed pill. The beauty of this product, RISUG (for reversible inhibition of sperm under guidance), is that it isn’t subject to human error like the pill, it isn’t hormonal like almost every female birth control, and it doesn’t break. U.S. politicians are in a race to reduce the abortion rate by restricting access but I’d bet the farm that this male birth control will do more than every law combined in reducing the rate of abortions. That is of course assuming men are taught about it.