Content uploaded by Liza Fuentes
Author content
All content in this area was uploaded by Liza Fuentes on Oct 21, 2018
Content may be subject to copyright.
VIEWPOINT
Volume 46, Number 3, September 2014
By Anu
Manchikanti
Gomez, Liza
Fuentes and
AmyAllina
Anu Manchikanti
Gomez is assistant
professor, School
of Social Welfare,
University of
California, Berkeley.
Liza Fuentes is senior
project manager, Ibis
Reproductive Health,
Oakland. Amy Allina
is deputy director,
National Women’s
Health Network,
Washington, DC.
In recent years, enthusiasm about long-acting reversible
contraceptive (LARC) methods has skyrocketed among
U.S. reproductive health care providers because of these
methods’ potential to budge the rate of unintended
pregnancy, which “stubbornly” persists at the same level
despite efforts over many years to reduce it.1 For too long,
LARC methods—IUDs and implants—have not been an
option that women could easily choose, because of a range
of barriers: lack of knowledge,2 providers’ low familiarity
and lack of training,3–5 cost6,7 and unavailability in clinics.8
While we strongly believe that these barriers should be
reduced so that LARC methods are an integral part of a
comprehensive method mix, we also are concerned that
unchecked enthusiasm for them can lead to the adop-
tion of programs that, paradoxically, undermine women’s
reproductive autonomy. Our concern is that when efforts
move beyond ensuring access for all women to promot-
ing use among “high-risk” populations through programs
and contraceptive counseling aimed at increasing uptake
of LARC methods, the effect is that the most vulner-
able women may have their options restricted. To avoid
this pitfall, it is vital that programs designed to promote
LARC methods put the priorities, needs and preferences
of individual women—not the promotion of specifi c
technologies—fi rst.
While the possibility that LARC promotion efforts can
undermine reproductive autonomy may seem remote
in the face of the myriad barriers women face in using
these methods, we believe that now is a pivotal time to
engage in a critical discussion of this topic, given that use
of LARC methods is on the rise,9 new clinical models are
showing success in reducing and eliminating barriers to
using them10,11 and many women have newfound access
to contraceptives thanks to provisions of the Affordable
Care Act.12 Such a discussion may illuminate the ways in
which narrowing the scope of possibilities for family plan-
ning program innovation to promoting a particular class
of technologies allows the widespread social inequalities
that underlie unintended pregnancy to become invisible.
It also may show how prioritizing method effectiveness
above other contraceptive features may deny some women
reproductive control.
SOCIAL AND REPRODUCTIVE
HEALTH INEQUALITIES
Clear disparities in levels of unintended pregnancy in the
United States persist: Rates are disproportionately high
among young, black, Latina and poor women.1 In an effort
to address such disparities, researchers and health care
providers have not only devised interventions to reduce
barriers women face in accessing LARC methods, but also
developed targeted strategies to increase these methods’
use among “high-risk” women.13,14 Interventions targeting
populations with the highest rates of unintended preg-
nancy may be seen as a sensible response to the fact that
such women have an unmet need for family planning and
as a sensible way to use limited resources to have a public
health impact. Yet, targeted approaches to LARC promo-
tion guided primarily by population-level statistical data
risk imposing “statistical discrimination”—using epide-
miologic data or previous clinical experiences to estimate
a particular woman’s risk, without consideration of her
unique history, preferences and priorities.15
The notion that membership in high-risk populations
may lead the least privileged women to receive contra-
ceptive counseling that steers them toward a particular
method is especially worrisome given the long-standing
devaluation of the fertility and childbearing of young
women, low-income women and women of color in the
United States, and the perception that these women have
too many children.16,17 The history of such reproductive
oppression is well documented, but the experience is
not merely historical: Between 2006 and 2010, women
in California prisons underwent coerced sterilizations,18
and as recently as 2009, some 19 states denied additional
cash benefi ts to families that had additional children while
receiving assistance.19
Furthermore, women continue to perceive racial dis-
crimination in family planning settings.20–24 In a national
study of black women, 67% of participants who had
seen a health care provider for family planning services
reported experiencing race-based discrimination when
obtaining these services.24 Other studies have found
that black women may feel pressured to use contracep-
tives,23 and black and Latina women are more likely
than white women to be advised to restrict their child-
bearing.21 Moreover, another study found that black and
Latina women were more likely than white women to be
counseled about birth control, but were no more likely
to obtain a method, suggesting that increased counseling
of minority women was not patient-initiated.20 These con-
cerns are all the more pressing because there is evidence
that providers, consciously or not, consider race and
socioeconomic status in making their recommendations
about the most appropriate contraceptive for a patient. In
a randomized trial of health care providers who watched
Women or LARC First? Reproductive Autonomy
And the Promotion of Long-Acting Reversible
Contraceptive Methods
Reproductive Autonomy and LARC Promotion
Perspectives on Sexual and Reproductive Health
space births, and achieve their desired family size, no mat-
ter their wealth.
BEYOND EMPHASIZING
EFFECTIVENESS ABOVE ALL
The framing of LARC methods as the fi rst-line contracep-
tives that should be offered to all women focuses on the
appeal of “forgettable” contraception,14 the lack of user
compliance required13 and, most important, their high
rates of effectiveness. However well-intended, such con-
ceptualization implies that these methods offer women
the most control over their reproduction—an implication
that may not be refl ected in the experiences of women
who are currently the least likely to use LARC methods.
For some women, optimal control may mean choosing
a method that will almost never fail. For others, optimal
control may mean choosing a method that can be started
or discontinued as they choose, without the assistance of a
health care provider.30 For still others, control might relate
to the effect of a method on the menstrual cycle. Further,
many factors beyond method effectiveness—for example,
side effects,31 detectability by a partner or parent,32,33
pregnancy ambivalence,34 the experiences of family and
friends,35 and relationship context36—infl uence method
selection and continuation. For a multitude of reasons,
even with perfect knowledge and no barriers to access,
many women still will not choose LARC methods. And as
long as a woman’s choice is based on accurate information
and a good understanding of her own priorities, that deci-
sion should be supported as a positive outcome.
Moreover, the realities of the current health care and
health insurance systems aggravate women’s potential lack
of control and may undermine the self-determination that
LARC users can achieve. The Affordable Care Act requires
insurers to cover all contraceptive methods approved by
the Food and Drug Administration, including LARC meth-
ods and the services necessary to support their use. But
because removal of an IUD or implant occurs at a different
time from placement and is thus billed separately, women
who lack or have inconsistent health insurance coverage
may still face fi nancial barriers to removal. In addition,
even insured women may face resistance from health care
providers if they are perceived as wanting to remove an
IUD or implant too early. While the option of self-removal
of IUDs may alleviate these barriers for some women, it is
only a partial solution, as most women are not aware of it,
and not all women will feel comfortable with it or will be
able to successfully remove an IUD.37,38
The success of the Contraceptive CHOICE Project,
which aims to promote the use of LARC methods39—
and, in particular, its fi nding that when cost barriers are
removed, women are much more likely to choose a LARC
method and to continue using it40,41—has critical policy
implications. While the high rates of LARC device uptake
and continuation among CHOICE participants are note-
worthy, it is important to acknowledge that the study is a
demonstration project, modeling the kinds of outcomes
videos depicting 27-year-old women of varying racial, eth-
nic and socioeconomic backgrounds, providers were more
likely to recommend IUD use for low-income black and
Latina women than for low-income white women.25
These experiences, policies and studies underscore the
reality that settings that serve the most vulnerable women
seeking contraceptive care do not operate in a neutral
context. Persistent racial and socioeconomic inequality
colors the daily lives of both providers and patients, and
is inextricably embedded in clinical encounters. Given
this context, the family planning community must make
particular efforts to ensure that women are able to freely
choose LARC methods: It must take steps to make cer-
tain that use of these methods is driven by women’s own
expressed desires for them, and not by a programmatic
attempt to reduce population-level unintended pregnancy
rates by encouraging “risky” women to use them.
Further, the increasing focus on LARC methods as the
solution to unintended pregnancy in the United States
neglects the role of social determinants of unintended
pregnancy. Compared with other middle- and high-
income countries, the United States has a disproportion-
ately high rate of unintended pregnancy, especially among
adolescents.26 Arguably, macro-level factors—increasing
economic inequality, lack of universal health care and
stigma related to sexuality—play a larger role in this phe-
nomenon than do low rates of LARC use.27,28 For example,
economists have noted that variation in state-level income
inequality accounts for much of the geographic disparity
in teenage childbearing in the United States, contending
that policies specifi cally targeting teenage pregnancy (e.g.,
sex education, improved access to contraceptives) are
unlikely to produce improved outcomes for the most dis-
advantaged young women.28 These data on teenage preg-
nancy illustrate that overly relying on LARC methods as
the solution to high levels of unintended pregnancy may
hinder innovation and political will to envision and fund
more integrated, structural efforts to improve family plan-
ning services and use.
Nationally recognized experts on poverty policy have
suggested that increased access to LARC methods will
reduce rates of nonmarital childbearing and poverty.29
Using rigorous research methods with appropriate com-
parison groups to investigate whether use of these meth-
ods has any impact on poverty is important; however, any
research of this kind must be designed with an under-
standing of how results could be used to inform policy—
in both intended and unintended ways. If such research
fi nds a causal association between LARC use and poverty
reduction, could that fi nding be used to ask, encourage or
even coerce women to use LARC methods simply because
they are poor? On the other hand, what if LARC use does
not bear on women’s future income? Communicating such
a null fi nding must not invalidate the much more impor-
tant reasons for continuing to ensure women and their
partners access to a full range of contraceptive options,
including LARC methods: so that they can plan for and
Even with
perfect
knowledge and
no barriers to
access, many
women still
will not choose
LARC methods.
Volume 46, Number 3, September 2014
agency in ways that approaches focused on specifi c tech-
nologies or contraceptive features, such as effectiveness,
cannot. These recommendations are intended not to
inhibit LARC promotion efforts, but rather to focus them
on increasing access for all women, rather than use among
target populations. The goal should be that every woman
has the opportunity to use a LARC method, meaning that
she has a provider who can and will give her the method,
without barriers like waiting periods; insurance that cov-
ers insertion and removal; and the knowledge to make an
informed decision.
Family planning clinical practice and training should
be developed with a woman-centered framework, which
supports each woman in identifying her family planning
priorities and in adopting the method that best meets her
current needs. Approaches that show promise in increas-
ing a woman’s ability to effectively use her selected method,
such as those used in the CHOICE Project, should be
understood and advanced in ways that ensure that IUDs
and implants are made accessible along with other com-
ponents of a comprehensive method mix. Likewise, train-
ing should go beyond a “LARC fi rst” counseling approach
and support providers in responding respectfully to a
woman’s concerns and, ultimately, her choice not to use
a LARC method, as legitimate and even successful. Given
that many women lack accurate information about con-
traception yet still have preferences and priorities,48 one
possibility is that counseling scripts be structured around
a ranking of women’s priorities for a method (e.g., can be
started and discontinued by women themselves; is highly
effective; is “forgettable”), rather than around method
effectiveness. Once a priority is identifi ed, methods that
meet it can be discussed. Some providers already use
open-ended approaches,49 and we believe that formaliz-
ing and testing such counseling techniques will offer more
opportunities for providers to support all women in get-
ting evidence-based information about the family plan-
ning methods in which they are most interested.
LARC promotion must expand—not restrict—contra-
ceptive options for all women, particularly for women
whose racial, ethnic or class identities have made them
targets of forced sterilization46,50 and of policies aiming to
restrict their fertility.44,51 Efforts to increase LARC use have
historically been mired in racial and class biases about
who is capable of managing the “hazard” of fertility and
who is valued as a mother in American society.52 When
LARC use is the “default outcome”11,47 specifi cally for
women who tend to have the fewest choices in life, repro-
ductive autonomy may be inadvertently restricted com-
pared with the autonomy of women who are not perceived
as being at high risk for unintended pregnancy. Looking at
an individual woman through the lens of a statistical risk
profi le neglects her particular context, which is undoubt-
edly critical to every woman’s decision making about fam-
ily planning.
Policy barriers to both LARC insertion and removal
must be eliminated. Programs promoting LARC use
we might expect when widespread intertwined barriers to
access, insurance coverage and funding are addressed.
In the CHOICE Project’s counseling model, women are
presented with information about contraceptive methods
from most to least effective, meaning that LARC methods
are presented fi rst.42 While the training materials confront
head-on the very real problem of low familiarity with
LARC methods by using evidence-based information and
emphasize the importance of women’s preferences, the
principle that effectiveness is the most important aspect
of a contraceptive technology is inherent in the model.
While this may be the case from public health and tech-
nology development perspectives, privileging effectiveness
in counseling may eclipse the range of concerns, prefer-
ences and priorities that individual women bring to their
contraceptive decision making.
This focus on effectiveness points to the perceived ten-
sion between the public health goal of reducing unin-
tended pregnancies and the individual and community
goal of ensuring that women have the resources and
knowledge to be able to effectively use a contraceptive
method of their choice. Family planning care is not excep-
tional in requiring programs and providers to balance
this tension. However, in family planning, this balance
is particularly fraught because of programs and policies
that are structured to prevent poor women and women
of color from having children.43–45 Given the historical
legacy and ongoing reality of reproductive coercion in
the United States—where low-income women, women of
color and other marginalized women have been sterilized
without their consent46 and been provided with welfare
benefi ts that are contingent upon contraceptive implant
insertion43—it is imperative for LARC promotion pro-
grams operating in communities that have been the target
of those policies to challenge this tension and prioritize
women’s reproductive autonomy.
An understanding of these realities and how they shape
our behaviors and assumptions must be integrated into
the design and delivery of family planning services. When
it comes to LARC methods, is there a risk that efforts
to increase uptake as a way to address the unintended
pregnancy rate could come at the expense of individual
women’s preferences and, ultimately, autonomy? Or at the
very least, might a clinical encounter in which a woman
chooses a less effective method or no method at all be seen
as a failure, particularly when LARC uptake is the “default
outcome”11,47 or a measure of clinical success or quality?
When a woman is provided counseling to steer her toward
the most effective methods, even if that is not her priority,
the public health imperative plays a more signifi cant role
than it does when counseling starts with the woman and
her concerns.
RECOMMENDATIONS
Our recommendations for improving the delivery of LARC
services refl ect our belief that woman-centered approaches
to family planning promote reproductive autonomy and
LARC
promotion
must
expand—not
restrict—
contraceptive
options for all
women.
Reproductive Autonomy and LARC Promotion
Perspectives on Sexual and Reproductive Health
meeting of the Association of Reproductive Health Professionals, New
Orleans, Sept. 18–21, 2013.
12. Finer LB, Sonfi eld A and Jones RK, Changes in out-of-pocket
payments for contraception by privately insured women during
implementation of the federal contraceptive coverage requirement,
Contraception, 2014, 89(2):97–102.
13. Spain JE et al., The Contraceptive CHOICE Project: recruit-
ing women at highest risk for unintended pregnancy and sexu-
ally transmitted infection, Journal of Women’s Health, 2010,
19(12):2233–2238.
14. Hillard PJA, What is LARC? And why does it matter for ado-
lescents and young adults? Journal of Adolescent Health, 2013, 52(4,
Suppl.):S1–S5.
15. Balsa AI, McGuire TG and Meredith LS, Testing for statisti-
cal discrimination in health care, Health Services Research, 2005,
40(1):227–252.
16. Geronimus AT, Damned if you do: culture, identity, privilege, and
teenage childbearing in the United States, Social Science & Medicine,
2003, 57(5):881–893.
17. Collins PH, From Black Power to Hip Hop: Racism, Nationalism, and
Feminism, Philadelphia: Temple University Press, 2006.
18. Johnson CG, Female inmates sterilized in California prisons with-
out approval, Berkeley, CA: Center for Investigative Reporting, 2013,
<http://cironline.org/reports/female-inmates-sterilized- california-
prisons-without-approval-4917>, accessed Feb. 12, 2014.
19. National Conference on State Legislatures, Family cap policies,
2009, <http://www.ncsl.org/research/human-services/welfare-reform-
family-cap-policies.aspx>, accessed Feb. 12, 2014.
20. Borrero S et al., The impact of race and ethnicity on receipt
of family planning services in the United States, Journal of Women’s
Health, 2009, 18(1):91–96.
21. Downing RA, LaVeist TA and Bullock HE, Intersections of ethnic-
ity and social class in provider advice regarding reproductive health,
American Journal of Public Health, 2007, 97(10):1803–1807.
22. Yee LM and Simon MA, Perceptions of coercion, discrimination
and other negative experiences in postpartum contraceptive counsel-
ing for low-income minority women, Journal of Health Care for the Poor
and Underserved, 2011, 22(4):1387–1400.
23. Becker D and Tsui AO, Reproductive health service preferences
and perceptions of quality among low-income women: racial, ethnic
and language group differences, Perspectives on Sexual and Reproductive
Health, 2008, 40(4):202–211.
24. Thorburn S and Bogart LM, African American women and fam-
ily planning services: perceptions of discrimination, Women & Health,
2005, 42(1):23–39.
25. Dehlendorf C et al., Recommendations for intrauterine contra-
ception: a randomized trial of the effects of patients’ race/ethnicity
and socioeconomic status, American Journal of Obstetrics & Gynecology,
2010, 203(4):319.e1–319.e8, <http://www.ajog.org/article/S0002-
9378(10)00578-8>, accessed Dec. 9, 2011.
26. United Nations, Department of Economic and Social Affairs,
Population Division, World Contraceptive Use 2012, New York: United
Nations, 2012.
27. Bachrach C et al., Unplanned pregnancy and abortion in the
United States and Europe: Why so different? Washington, DC:
National Campaign to Prevent Teen and Unplanned Pregnancy, 2012.
28. Kearney MS and Levine PB, Why is the teen birth rate in the
United States so high and why does it matter? Journal of Economic
Perspectives, 2012, 26(2):141–166.
29. Haskins R, Poverty and opportunity: Begin with facts,
Washington, DC: Brookings Institution, 2014, <http://www.
should ensure that the cost of device removal is automati-
cally covered at the time of insertion, eliminate protocol
and de facto barriers to removal (e.g., requirements that a
woman keep an implant or IUD for a minimum amount of
time before removal), and support clinicians in discussing
the option of self-removal with women.
CONCLUSION
To fully realize the promise of LARC methods to sup-
port reproductive autonomy and health for women, we
must also consider that the promotion and uptake of any
contraceptive technology takes place in social and politi-
cal contexts that historically and currently subjugate low-
income women and women of color—those most likely
to experience unintended pregnancy.1 Such a discussion
by no means diminishes the tremendous importance of
continuing to eliminate structural and clinical barriers to
LARC use; indeed, it can highlight issues, such as insur-
ance coverage for IUD removal, that are not always rec-
ognized as concerns. We can increase women’s ability
to prevent and plan pregnancies by ensuring that as we
devise solutions that eliminate barriers to LARC use for all
women, we do not inadvertently diminish the reproduc-
tive autonomy of some women.
REFERENCES
1. Finer LB and Zolna MR, Unintended pregnancy in the United
States: incidence and disparities, 2006, Contraception, 2011,
84(5):478–485.
2. Kaye K, Suellentrop K and Sloup C, The Fog Zone: How
Misperceptions, Magical Thinking, and Ambivalence Put Young Adults at
Risk for Unplanned Pregnancy, Washington, DC: National Campaign to
Prevent Teen and Unplanned Pregnancy, 2009.
3. Tang J, Maurer R and Bartz D, Intrauterine device knowledge and
practices: a national survey of obstetrics and gynecology residents,
Southern Medical Journal, 2013, 106(9):500–505.
4. Harper CC et al., Evidence-based IUD practice: family phy-
sicians and obstetrician-gynecologists, Family Medicine, 2012,
44(9):637–645.
5. Harper CC et al., Counseling and provision of long-acting revers-
ible contraception in the US: national survey of nurse practitioners,
Preventive Medicine, 2013, 57(6):883–888.
6. Eisenberg D, McNicholas C and Peipert JF, Cost as a barrier to long-
acting reversible contraceptive (LARC) use in adolescents, Journal of
Adolescent Health, 2013, 52(4, Suppl.):S59–S63.
7. Thompson KMJ et al., Contraceptive policies affect post-abortion
provision of long-acting reversible contraception, Contraception, 2011,
83(1):41–47.
8. Beeson T et al., Accessibility of long-acting reversible contra-
ceptives (LARCs) in federally qualifi ed health centers (FQHCs),
Contraception, 2014, 89(2):91–96.
9. Finer LB, Jerman J and Kavanaugh ML, Changes in use of long-
acting contraceptive methods in the United States, 2007–2009,
Fertility and Sterility, 2012, 98(4):893–897.
10. Peipert JF et al., Preventing unintended pregnancies by pro-
viding no-cost contraception, Obstetrics & Gynecology, 2012,
120(6):1291–1297.
11. Romer SE and Teal S, The BC4U service model: achieving astro-
nomical LARC uptake in adolescents, paper presented at the annual
Volume 46, Number 3, September 2014
43. Roberts D, Killing the Black Body: Race, Reproduction, and the
Meaning of Liberty, New York: Pantheon Books, 1997.
44. Romero D and Agénor M, US fertility prevention as poverty pre-
vention: an empirical question and social justice issue, Women’s Health
Issues, 2009, 19(6):355–364.
45. Gutierrez ER, Fertile Matters: The Politics of Mexican-Origin
Women’s Reproduction, Austin, TX: University of Texas Press, 2008.
46. Stern AM, Sterilized in the name of public health: race, immigra-
tion, and reproductive control in modern California, American Journal
of Public Health, 2005, 95(7):1128–1138.
47. Stevens J and Berlan ED, Applying principles from behavioral
economics to promote long-acting reversible contraceptive (LARC)
methods, comment, Perspectives on Sexual and Reproductive Health,
2014, doi: 10.1363/46e0614, accessed Feb. 13, 2014.
48. Lessard LN et al., Contraceptive features preferred by women
at high risk of unintended pregnancy, Perspectives on Sexual and
Reproductive Health, 2012, 44(3):194–200.
49. Hatcher R, Trussell J and Nelson A, Contraceptive Technology, 20th
ed., New York: Ardent Media, 2012.
50. Kluchin RM, Fit to Be Tied: Sterilization and Reproductive Rights in
America, 1950–1980, New Brunswick, NJ: Rutgers University Press,
2011.
51. U.S. General Accounting Offi ce, Welfare Reform: More Research
Needed on TANF Family Caps and Other Policies for Reducing Out-of-
Wedlock Births, Washington, DC: U.S. General Accounting Offi ce,
2001.
52. Takeshita C, The Global Biopolitics of the IUD: How Science
Constructs Contraceptive Users and Women’s Bodies, Cambridge, MA:
MIT Press, 2012.
Acknowledgments
The writing of this viewpoint was supported by grant
K99HD070874 from the Eunice Kennedy Shriver National Insti-
tute of Child Health and Human Development, National Institutes
of Health (NIH). The content is the responsibility solely of the au-
thors and does not necessarily represent the offi cial views of the
NIH. The authors thank Lisa Harris, Daniel Grossman, Jessica
Wolin, Laura Mamo, Sonja Mackenzie, Allen LeBlanc, Anoshua
Chaudhuri and Susan Zieff for providing critical feedback on early
drafts.
Author contact: anugomez@berkeley.edu
doi: 10.1363/46e1614
brookings.edu/research/testimony/2014/01/28-poverty-opportunity-
begin-with-facts-haskins>, accessed Feb. 6, 2014.
30. Gomez AM and Clark J, Method mismatch: discrepancies between
young women’s contraceptive preferences and current method choice,
poster presented at the North American Forum on Family Planning,
Seattle, Oct. 6–7, 2013.
31. Gilliam ML et al., Concerns about contraceptive side effects
among young Latinas: a focus-group approach, Contraception, 2004,
70(4):299–305.
32. Garcia L, Respect Yourself, Protect Yourself: Latina Girls and Sexual
Identity, New York: NYU Press, 2012.
33. Yee L and Simon M, The role of the social network in contra-
ceptive decision-making among young, African American and Latina
women, Journal of Adolescent Health, 2010, 47(4):374–380.
34. Turok DK et al., A survey of women obtaining emergency contra-
ception: Are they interested in using the copper IUD? Contraception,
2011, 83(5):441–446.
35. Gilliam ML et al., Familial, cultural and psychosocial infl uences
of use of effective methods of contraception among Mexican-American
adolescents and young adults, Journal of Pediatric and Adolescent
Gynecology, 2011, 24(2):79–84.
36. Kusunoki Y and Upchurch DM, Contraceptive method choice
among youth in the United States: the importance of relationship con-
text, Demography, 2011, 48(4):1451–1472.
37. Foster DG et al., Interest in using intrauterine contraception
when the option of self-removal is provided, Contraception, 2012,
85(3):257–262.
38. Foster DG et al., Interest in and experience with IUD self-
removal, Contraception, 2014 (forthcoming).
39. Secura GM et al., The Contraceptive CHOICE Project: reducing
barriers to long-acting reversible contraception, American Journal of
Obstetrics & Gynecology, 2010, 203(2):115.e1–115.e7, <http://www.
ajog.org/article/S0002-9378(10)00430-8>, accessed Feb. 13, 2014.
40. Peipert J et al., Continuation and satisfaction of reversible con-
traception: a preliminary analysis from the Contraceptive CHOICE
Project, Contraception, 2010, 82(2):193–194.
41. O’Neil-Callahan M et al., Twenty-four-month continua-
tion of reversible contraception, Obstetrics & Gynecology, 2013,
122(5):1083–1091.
42. Madden T et al., Structured contraceptive counseling pro-
vided by the Contraceptive CHOICE Project, Contraception, 2013,
88(2):243–249.
