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Opinion and Commentary from TMA

LARCs and the Burden of History

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Editor’s note: This article was originally published in the May 2018 edition of the Texas Health Journal, published by The University of Texas System Population Health Initiative. Reprinted with permission. It focuses on the work of Edinburg obstetrician-gynecologist Tony Ogburn, MD, to expand women’s use of long-acting reversible contraceptives (LARCs). Women who are better able to plan and space their pregnancies have lower health risks before and after their babies are born. That’s why expanding the availability and use of LARCs is a key recommendation that came out of the 2018 Texas Medical Association Maternal Health Congress. The TMA House of Delegates will consider those recommendations when it convenes in San Antonio on May 18 and 19. 


Dr. Tony Ogburn, founding chair of the Department of Obstetrics and Gynecology at the University of Texas Rio Grande Valley (UTRGV) School of Medicine, has spent much of his career in women’s health trying to close the gap between two realities. 

The first reality is that almost half of pregnancies in the United States are unintended, which may increase the risk that women will suffer postpartum depression and fail to receive early prenatal care, among other risks. Even the risk of severe outcomes, like infant and maternal mortality, may go up when pregnancies are unintended.

The second reality is that unintended pregnancies are easier than ever to prevent. There are a range of contraceptive methods that are effective, easy to use, and inexpensive. In particular, for Ogburn, there are long-acting reversible contraceptives, or LARCs.

LARCs, which include intrauterine devices (IUDs) and implants like Nexplanon, are highly effective in preventing pregnancy, last for an extended period of time and, once inserted, work without user action. The combination of these elements, in fact, make them the single most effective method of contraception. They are also, however, one of the most distrusted by the public, and one of the hardest to access even for women who are interested. 


When LARCs were first introduced in the 1950s, the devices worked at preventing most patients from getting pregnant. However, an early version of the IUD, called the Dalkon Shield, was difficult to insert and had high incidence of infection, infertility and Pelvic Inflammatory Disease. In 1974, when the Department of Health, Education and Welfare ordered family-planning clinics to stop prescribing it, roughly 3 million people were using the Dalkon Shield IUD. The devices were pulled from the shelves, many women had their IUDs removed, and the manufacturer filed for bankruptcy.

Although IUDs used in the U.S. today are dramatically safer, misconceptions over the method’s safety persist from decades ago. 

“It's not uncommon that a patient will come in for a LARC consultation and their mom or aunt says, ‘Oh no, those are dangerous’ or ‘They don’t keep you from getting pregnant’ or ‘They can cause an infection’. So there's still a generation of women that have very negative attitude about LARCs,” Ogburn said.

It’s getting better, though, said Ogburn. He’s seen a shift in the public perception of these birth control methods, over the last decade, as more information emerges, and misconceptions are corrected. OBGYNs and other organizations used to only recommend LARCs as a last resort. Now, they’re the preferred primary birth control method for most providers, and for many women. 

“When I first started really getting involved in family planning, the usage rate of LARCs around the country was about 1 to 2 percent of women who were using contraception,” Ogburn said. “Now, depending on the patient’s age and the area of the country, that rate’s somewhere around 10 or 11 percent. It's been a dramatic increase.”

But outdated misconceptions and unfounded fears aren’t the only barriers to LARC use. Access to clinics and clinicians trained to insert long-acting reversible contraception remains a serious problem for many patients In the Rio Grande Valley, as well as in many other underserved areas. To help combat this, the UTRGV School of Medicine has started residency programs in Ob/Gyn and Family Medicine that provide comprehensive training in contraception, including in the use of LARCs. 

“We're the first medical school based in the region,” Ogburn said. “Before UTRGV opened, there was a gap in the community in terms of LARC training, both for IUDs and implants. So myself, as well as several of my faculty, have held numerous trainings with clinicians, community groups, hospitals and the nurse-family partnership.”

The opening of the medical school represents one of the biggest steps forward for the region’s ability to provide healthcare for women, Ogburn said. The school’s physicians are now able to spread the word about LARCs, provide training to more providers, and help allay misconceptions. The medical school has only been open for two years, but there is tremendous optimism that many of the future physicians who train in the Valley will stay in the region after completing medical school. 

That will be one of the most beneficial aspects for women and maternal health, according to Ogburn. 

“The new physicians will be familiar with the community, they will be newly trained in evidence-based practices, and they will incorporate them in the community,” Ogburn said.

The ability to plan your pregnancy is a vital component to healthy pregnancies, healthy moms and a healthy family, Ogburn said, and women's health really is one of the keys to the overall health of a community.

“Nationally, the unintended pregnancy rates have gone down by about five percent over the last 25 years — from 50 percent to 45 percent. I think there's very little question that the increased use of LARCs have definitely influenced that,” Ogburn said. 

“To keep from getting pregnant is critical for the issues that we have, not only in Texas but nationally, in terms of maternal mortality and morbidity and neonatal health,” he added. By helping women control if and when they become pregnant, LARCs can help strengthen the overall health of Texas communities.

Shelby Knowles, is pursuing a master’s degree in journalism through The University of Texas System’s Population Health Scholar program