WILMINGTON, DE — Early in the morning on March 17, staff from a nonprofit called Upstream USA arrived at a Delaware health clinic. They showed up with some typical supplies: three Dunkin' Donuts coffee jugs, two dozen doughnuts, countless paper handouts, and one mechanical vagina.
The mechanical vagina — which, much like its human counterpart, is attached to a (mechanical) cervix and uterus — was certainly the most unusual cargo. But it was important: The 40-pound replica of the female reproductive system allows nurses and doctors to practice new procedures. On that Thursday morning, it was where two nurses learned how to insert an intrauterine device (IUD) into a patient.
"You want to have fewer than four pain events," Ian Baxter, an instructor for the event, tells the two nurses. The machine squeals in pain — a recording of a woman saying, "Ow!" — if the practitioner pushes too hard or in the wrong direction.
The two nurses work at the Life Health Center in Wilmington, a reproductive health–focused clinic that serves mostly low-income women. The site is part of a new and potentially massive experiment in American health care that aims to give all women access to the most effective contraceptives — and see what happens next.
The IUD evangelists
Birth control pills are currently the most popular contraceptive among American women, followed by condoms. These methods are especially susceptible to human error and have high failure rates. Of 100 women who rely on birth control pills, about six get pregnant every year.
By contrast, long-acting reversible contraceptives (LARCs) like IUDs and implants are placed by health professionals and last for at least three years after insertion. They are 20 times more effective at preventing pregnancy than the pill, with failure rates between 0.2 and 0.8 percent.
The most recent data shows that about 12 percent of contraceptive users choose LARCs. Many more likely would if they had easier access. Right now the devices can be expensive and require multiple trips to the doctor. Studies find that only about half of those who say they want an IUD come back for a follow-up insertion appointment.
Upstream USA aims to change that by making same-day access to LARCs available nationwide. The group has worked in about 20 clinics so far, in places that range from Texas to Massachusetts. Earlier this year, Upstream signed its first statewide contract to train 60 sites in Delaware.
"Our goal is to be out of business in 15 years," says the group's co-founder Mark Edwards. "We want to go out there and get all clinics trained in that period of time. There's no reason we can't do that."
Edwards points to recent experiments in Colorado and St. Louis, Missouri, as proof of why this can work. In both places, unintended birth and abortion rates plummeted after women gained expansive access to LARCs.
Edwards sees Colorado as a success story — but it ought to also be viewed as a cautionary tale. Though the program drove down teen abortion and birth rates significantly, the state legislature voted against funding it in 2015.
IUDs tinged the program with controversy; some conservative groups argued that the devices could cause abortions by stopping a fertilized egg from attaching to the uterine lining. (Doctors disagree with this definition of abortion, saying that pregnancy begins after the fertilized egg attaches to the lining.)
The health department had to scramble to find last-minute funds from private foundations to keep the birth control program running.
"As wonderful as it is to receive all these national accolades, it's also really challenging to continue to be a LARC leader when our funding is so challenged," says Jody Camp, the section manager for family planning at the Colorado Department of Health and Environment.
The Colorado experience suggests that expanded access to better contraceptives could play a huge role in reducing unintended births. It also shows that the American political system is not quite yet ready.
Gynecologists think IUDs are the best contraceptive. They also struggle to provide access.
IUDs and implants are better at preventing pregnancy than pretty much any other available contraceptive.
Most LARCs work similarly to other contraceptives, using hormones to prevent sperm from fertilizing an egg. (The exception to this is the IUD Paragard, which uses copper ions rather than hormones to achieve the same result.) What makes LARCs work better than the birth control pill, patch, or ring is that the device doesn't require any work on the part of the user.
This is why the American College of Obstetricians and Gynecologists recommends IUDs and implants as the "first-line" contraceptive that should be "encouraged as an option for most women," including adolescents.
LARCs are a fantastic contraceptive, but they only work if women can actually use them. Patients have generally faced three big obstacles in obtaining IUDs and implants: cost, education, and access.
1) Implants and IUDs can cost upward of $500, whereas a generic pack of birth control pills can cost as little as $5 to $15 per month for those with insurance (or $20 to $50 for those without). Obamacare attempts to tackle this problem by requiring all insurance companies to cover LARCs at no cost to the patient.
2) There are lots of myths about LARCSs that persist among both patients and providers. These include beliefs like only women who have already had children are good candidates for IUDs (not true) or that a woman must be on her period to have the device placed (also false). I personally encountered both of these myths when I got an IUD; one doctor at a private clinic in downtown Washington refused to place the device because I'd never had a child.
3) Finally, there's access: Clinics often struggle with the logistics of providing LARCs.
The insertion process is quick – about five minutes or so from start to finish. But doctors might not have blocked out that time or have the pricey device in stock (a handful of $500 IUDs sitting on the shelf can create cash flow challenges, especially in small clinics). Many clinics will ask women to return for a second appointment.
This last obstacle, reproductive health experts say, is a huge problem. Studies show that many women will never return for that second appointment. One 2012 study of 708 Medicaid patients showed that only 54.4 percent of patients who requested an IUD showed up for the insertion appointment. Women who lived more than 10 miles from a clinic were especially likely to become no-shows.
Another study of women who intended to get IUDs after an abortion found that only 32 percent actually received the device. When those who didn't show up for the second appointment were asked why, they said that they just didn't have time for an additional visit.
Cheryl Chastine, an abortion provider in the Midwest, says she often has patients who request LARCs but doesn't have enough money to keep them in stock. So she refers her patients to outside providers.
"At least half of my patients that I've seen for a second abortion, I can see, documented in their charts, that we've discussed a long-acting, reversible method of contraception and they said they wanted it," she says. "They leave, and they have chaotic lives. So when I see them again, they'll say that they couldn't get child care to get to the doctor.
"I see many more patients back here than I would if they had actually gotten the type of contraceptive they wanted."
This is why Upstream USA isn't just focused on getting IUDs into clinics — it's also focused on creating a workflow that allows providers to insert the devices within moments of a patient's request. And that means changing how any clinic that provides birth control works.
A surprising launch in deep red Texas — and a big experiment in Delaware
Mark Edwards is a guy who likes to found things. He launched his own communications firm in 1984, which worked largely with high schools and universities. In 2009 he founded Opportunity Nation, a campaign involving 250 nonprofits working to expand economic opportunity.
In late 2014, Edwards began working with Peter Belden (who had worked on reproductive health issues in California) to start a new nonprofit that would focus on expanding access to contraceptives, which he called Upstream USA.
Upstream USA launched in November 2014 in the place where Edwards felt it was least likely to succeed: Texas. "We went there in part because people said that you can't do this in a red state," he says.
The group first worked with the Health Haven clinic in Amarillo. It's in a county that has a teen birth rate three times the national average.
In 2010, 10.8 percent of girls there between 15 and 19 had babies. For Texas, the figure stood at 6.3 percent; nationally, it was 3.4 percent.
The clinic's providers got the training they needed to provide LARCs to patients. But the work went far beyond the basic medical procedure. The clinic support staffers were trained to ask the same question to pretty much every female patient who walked through their doors: "Do you intend to get pregnant within the next year?"
If the answer was no, they would start counseling on different contraceptive options, talking about the efficacy of LARCs and why they might be the best choice.
Before the Upstream training started, 5 percent of Health Haven clients chose LARCs. Within five months that figure more than tripled, hitting 17 percent.
Upstream has since worked at about 20 clinics across the country. Its most ambitious project, by far, is a partnership with Delaware to train 60 clinics across the country to offer same-day LARCs. Announced this past January, it's the group's first statewide partnership.
Delaware has the highest unintended pregnancy rate in the country — 62 per every 1,000 women between 15 and 44. Fifty-seven percent of the pregnancies in the state are unintentional.
"I used to understand birth control as a way to prevent abortion," Delaware Gov. Jack Markell told me in a recent interview. "That's true, but now I have a different way of looking at it. This is really an issue about opportunity, and the opportunities women get when they have children when they want to."
The Delaware and Upstream partnership is how the mechanical vagina — and a team of Upstream staff members — ended up traveling to the Life Health Center in Wilmington.
Forrest Watson, the clinic's executive director and founder, estimates that about half of his patients' pregnancies are unplanned.
Watson has tried to offer his patients better contraceptives like IUDs. But he ran into immediate obstacles, such as getting staff trained or even just buying the devices, which could cost upward of $900 per device. If a woman requested the device, his staff would have to refer her elsewhere.
Upstream USA is helping Watson solve those problems. It helped him join a group purchasing organization to gain access to cheaper devices — essentially, a bulk discount. While providers practiced LARC insertion, five members of their support staff were trained on how different contraceptive methods work. They did role playing, pretending to counsel one another on common LARC questions like, "Will my partner feel it during sex?" or, "What if I want to get pregnant?"
The training took place on March 17 and 18. Watson estimates that by April 1, his clinic will be providing same-day access to LARCs.
"It will empower our patients, I think," Watson told me in an interview as training was wrapping up. "This is a really significant step for us."
Clinics are ready for a birth control revolution. Legislators might not be.
Right now, much of the work around IUDs and implants has benefited from private philanthropy. State legislatures have been less enthused about supporting the efforts, which suggests a possible limitation to how far the work of a group like Upstream USA can spread. Nowhere is that more evident than Colorado.
Since 2009, Colorado has run a remarkable birth control experiment. The state has used $30 million from an "anonymous donor" to provide 36,000 low-income women with no-cost IUDs and implants.
The Colorado Family Planning Initiative showed quick results. By 2011, LARC use among Colorado women between 15 and 24 nearly quadrupled, increasing from 5 to 19 percent. Teen births fell 40 percent between 2009 and 2013, and abortion rates declined 42 percent. Not all of this was due to the program — nationally, abortion and birth rates also fell during this time frame — but independent researchers say the LARC access certainly played a significant role.
The results were widely covered in the media; the New York Times ran a front-page story about Colorado's program, describing it as a "startling success." The state received national awards for its work.
Armed with those glowing reviews, the Colorado Family Planning Initiative asked the state legislature for $5 million to run the program an additional year. The legislature said no.
The health department ultimately did secure $2.6 million from local foundations to keep the program afloat. But it doesn't think it can rely on private philanthropy forever — funders made it clear this was a one-time offer — so it's going back to the legislature and making its request a second time.
This time, the health department cut its budget request down to $2.5 million and changed the funding request to cover a wider array of reproductive services — an attempt to make it seem less focused on the IUDs that proved controversial in the last go-around.
"I am not confident the legislature will approve the $2.5 million item," Jody Camp at the health department says. "In some ways, we're staring down a bit of a shortfall."
Colorado's challenge may be one that Upstream clinics will eventually face too.
Carolena Cogdill runs Haven Health in Texas, Upstream's first partner. After the training finished in early 2015, Cogdill still knew she needed money to pay for the actual devices, and started submitting grant applications to local foundations.
"The boards were all old white men, and I was thinking, well, I'll just submit this and see what happens," she says. "They funded us at the full amount we requested."
Cogdill ended up with a huge success: Local foundations gave her $130,000 in grants, which she now uses to keep implants and IUDs in stock. At the same time, she's not quite sure where she'll get the next round of funding. The state, which recently made big cuts to its family planning programs, hasn't proven the most reliable source of funding.
Private philanthropy is funding the bulk of Delaware's $15 million project, too. The state is chipping in $1.7 million.
That model can work in a small state, where a wealthy donor can make a big difference, but it likely won't scale up to somewhere like Texas or California.
Edwards is cognizant of this fact.
He says that the group does their best to ensure clinics bill properly for IUDs and implants, maximizing their revenue from insurance plans. But they also need to think about how to cover uninsured patients, particularly in states where the political climate might not be favorable.
"That is the billion question," he says of how they'll continue to fund their work as their reach expands. "We know that private philanthropy is going to be a part of work, but we're also exploring other revenue models to scale at the rate that we'd like."
Vox Featured Video