"When you can't afford a choice it's not a choice at all."
This month, a new IUD became available to American women, and it may be a game changer, not because the design is particularly innovative but because it shatters the monopoly that has put top tier contraceptives out of reach for many women and made them less available in primary care settings.
Around the world, intrauterine contraception is one of the most widely used forms of reversible birth control. It is also the method most widely used by OB-GYN doctors, for good reason: an IUD is more than 20 times as effective as the Pill. It is also far cheaper in the long run. That is true even without taking into account the saved financial costs of contraceptive failure that produces abortion, pregnancy-caused health problems, or unsought childbearing.
Low Costs, Prohibitive Pricing
When I say cheaper, I mean a lot cheaper. A nonhormonal copper IUD costs as little as 40 cents U.S. to produce, and according to recent research, keeps working for as long as 20 years. (That's the production cost of a single box of condoms.) A hormonal IUD, which is preferred by many women because it makes periods lighter and less frequent and has other health benefits, costs a bit more. But the production cost is still remarkably inexpensive once research and development costs are paid back.
But monopoly pricing has put top tier birth control methods like IUD's and implants out of reach for many women in the United States. My two daughters got hormonal IUD's before heading to college, paid for by our "cadillac" medical insurance. The total bill for each of them was close to $1200, with the IUD itself being about two thirds of that. Today retail pricing on IUDs in the U.S. ranges from around $650 to $900 without the insertion procedure. By contrast, an IUD in Canada can cost as little as one tenth as much.
Even at these exorbitant prices, an IUD more than pays for itself over time, which is why monopolists have gotten away with pushing the pricing so high; but the upfront cost can be an insurmountable barrier for women without either excellent insurance or a flush bank account. That has been a tremendous frustration for people who care about fair access to family planning—or about social justice or gender equality, or flourishing families more broadly.
When pregnancy comes unsought, dreams and goals can get knocked aside, whether those are big future-oriented dreams like college education or military service, or small every-day ones, like parent time for kids already at home. A women who isn't in control of her fertility isn't in control of her life, and when prohibitive pricing forces women to rely on less reliable birth control methods, poor families get hit the hardest.
The two most popular IUDs on the market in the United States, the copper Paragard and the hormonal Mirena, were developed by the Population Council, a nonprofit with the express mission of serving women across the income spectrum. But once the technology was licensed to pharmaceutical companies, the drive to maximize profits took over and safeguards to ensure broad access failed.
Barriers after Affordable Care Act
The Affordable Care Act required that insurance plans cover all FDA approved contraceptives without a co-pay, but the high IUD cost has remained a barrier for many women. Some women are not covered because they work for Hobby Lobby types (whose sincerely held religious beliefs about how IUD's function are, by the way, factually wrong). Other women are undocumented and have to pay all medical care out of pocket.
Clinics serving low income women sometimes ration the best contraceptives to contain costs. Others order an expensive IUD only after a woman comes in asking for one, which requires her to make a second visit. When women need emergency contraception, doctors sometimes offer cheaper pills rather than the more effective copper IUD, and despite the fact that this violates ethical informed consent standards, they may not tell a woman that a much more effective method is available, should she prefer it.
Even for insured women, insurance companies seeking to cut costs may use a "reasonable management" loophole and require a woman to try a series of other methods first before she can get long acting birth control. And many don't cover an IUD or implant inserted at the time of labor and delivery, even though this is the best way to prevent rapid repeat pregnancies.
In other words, the high up front cost of long acting contraceptives creates pressure on both doctors and insurance companies to offer substandard medical care.
Philanthropic – Private Partnership
Enter Medicines360, a mission-driven pharmaceutical company with a focus on removing barriers that keep women from getting the best contraceptive choices, including awareness, education and cost. The company spent the past six years working to bring American women an affordable choice. The Liletta IUD, which is comparable in shape and function to the Mirena, will be offered to federally qualified health centers serving low income women for less than one fifth of what they are paying today, and will substantially drop wholesale IUD price for other clinics as well.
With funding from an anonymous foundation, Medicines360 combined a widely used medical device material and contraceptive hormone, and then took Liletta, a 52mg levonorgestrel-releasing intrauterine system through the research and FDA regulatory process. Their study included more than 1500 women from age 16 to 45, across the race and weight spectrum, both those who have and have not had babies. At the three year mark, results showed that the IUD was comparably safe and effective across all of these groups. The research is ongoing, and if similar products are any indicator, Liletta probably will be effective for five to seven years.
Choices Save Lives
No family planning method is a fit for every woman, and no effective method is side effect free. But because pregnancy itself is inherently risky, all common birth control methods are safer than not using contraception, and the most effective methods have the best health outcomes overall. Over 600 American women die each year from pregnancy and childbearing, around 200 of those from pregnancies they hadn't intended. Millions have short or long-term medical problems. For a woman who wants a child, the risks are well worth it; but they place a huge health burden on those who might prefer not to have another baby, or to wait. Dropping the cost of excellent long acting contraceptives reduces this burden on those who are least able to take the hit of a surprise pregnancy, women who are young and poor.
In coming years, other contraceptive technologies, now in the pipeline, may offer women a still wider range of options. The Population Council is currently testing a vaginal ring that is good for up to 12 months in contrast to today's NuvaRing, which much be replaced each month and requires refrigeration until used. An "intrauterine ball" that looks more like jewelry than contraception recently became available in some European countries. And we still need better birth control for men! But breaking the IUD monopoly is a great step in terms of giving more women another choice, because as Dr. David Eisenberg at Washington University puts it, "When you can't afford a choice, it's not a choice at all."