For years now, the IUD has supposedly been poised for its big comeback. Doctors, reproductive health advocates, and countless articles in the popular press have sung its praises for being more effective than the pill, lauded its safety and ease of use, and encouraged women to look past its unfortunate history. But while its popularity has inched up over the years— fewer than 1 percent of contraceptive users relied on the IUD in 1995, but by 2006-08, 5.5 percent used it—it is still a distant also-ran when compared to blockbuster reversible contraceptives like the pill, chosen by 28 percent of contraception users and the male condom, favored by 16 percent of contraception users.
The IUD's continued lack of popularity is often blamed on the Dalkon Shield, a 1970s-era IUD that injured more than 200,000 women. But with the Dalkon Shield's memory increasingly distant, a more immediate obstacle to the IUD today may be money. A 2004 survey commissioned by the Association of Reproductive Health Professionals found that only 42 percent of employers surveyed included IUD placement in their insurance benefits. For the majority of women who must pay for the device out pocket, either because they don't have insurance or because their plan doesn't cover the IUD, getting one can be prohibitively expensive—over $1,000 in all. One doctor I spoke to, Noa'a Shimoni, a family practitioner and a member of Physicians for Reproductive Choice and Health, told me that she does what she can to get around the cost barrier by using IUDs that are donated by drug companies, among other tactics. Still, she concluded, under the status quo, "Very few poor women are going to get the IUD."
All this is about to change. Earlier this month, the Department of Health and Human Services announced that it was classifying contraceptives (among a whole slate of women's health services) as preventative care, meaning that under the Affordable Care Act, insurers must provide these services without a co-pay starting in 2013. You wouldn't necessarily know it from the news coverage of the announcement—much of which focused on how the pill would now be free—but this has the potential to remake American women's relationship with birth control in profound ways. Although it may go without saying, lowering (or removing) the cost of something typically increases demand for it.
In the next few years, the number of American women who have access to free IUDs will expand dramatically, and not just because the already-insured will gain IUD coverage. The Affordable Health Care Act should also move the 22 percent of uninsured American women of reproductive age into insurance plans, where they, too, will be able to access IUDs at no cost. Between these millions of women who will now have access to free IUDs for the first time, and the gynecologists who have in recent years begun championing the contraceptive, the groundwork has finally been laid for a surge in the number of women who, after years of being discouraged by its high upfront costs, may finally choose the IUD.
Two major studies looking at the relationship between contraceptive cost and use have suggested that removing the economic barrier to getting the IUD should have a major impact on demand for the device. In 2002, the Kaiser Foundation Health Plan in California adjusted its benefits to make both the IUD and injectable contraceptives free. From 2000-01 to 2003-04, IUD use rose 137 percent. Cost wasn't the only thing that led to this sharp increase—the benefit change coincided with an effort to educate health-care providers about IUD safety—but the researchers who studied Kaiser's experience concluded that it was the combination of education and, crucially, cost savings that led so many women to adopt the IUD.
Even more dramatic are the results of an extensive study undertaken by Jeffrey Peipert of Washington University in St. Louis . In 2006, Peipert launched a massive effort that provided 10,000 women with both contraception education and no-cost access to whatever contraception they chose after the counseling *. The combination of the two interventions changed women's contraceptive choices dramatically: After going through the counseling, half of the women in Peipert's project chose the IUD. This rate of IUD usage so exceeded expectations that, as Peipert told the Washington University Record, the study ran well over budget.
History shows that costs have long impacted women's choice of contraception. Consider the diaphragm, which never achieved much use outside the bathrooms of married, middle-class women. "One reason diaphragms were used mainly by the middle class is that contraception was illegal in many states," Elaine Tyler May, author of America and the Pill: A History of Promise, Peril, and Liberation, told me, referring to the years before 1965, when the Supreme Court overturned laws banning contraception for married women. "So to get fitted in those states, you needed a doctor to prescribe it as a health measure." That kind of medical care was too expensive for many women, however, cementing the diaphragm's reputation as a middle-class contraceptive.
The pill, by contrast, benefitted strongly in its early days from the combination of low- and no-cost access and extensive education. May says that researchers conducting large-scale oral contraceptive trials found that women generally flocked to get the free contraception, even when it was untested. "There was a waiting list," May says of the pill's initial large-scale studies in Puerto Rico in the 1950s. "Women waited in lines, even though it was an experimental form. They wanted an effective and reversible contraception, rather than sterilization, which was widely available at the time. And yeah, the pill was free." In the decades since, May says, deep discounts at Planned Parenthood and campus health centers have helped make the pill the most popular form of contraception for women in their teens and 20s, a population that could certainly benefit from the IUD. (Gynecologists are only now beginning to realize that young women who want to delay childbearing for a decade or more may be an even better market for IUDs than women who already have children, the audience that IUD advertising currently targets.)
Although the IUD has been around in one form or another even longer than the pill, it may finally have a chance to escape the diaphragm's fate as an upper-middle class contraceptive. Already, stepped-up efforts to educate physicians and patients about the device have led to a four-fold increase in its use since 1995. Soon, with cost no longer a barrier, the IUD may reach a tipping point at which most women find that they have at least one friend who is using it. When that finally happens, women will be far likelier to consider it for themselves. And since the IUD is the reversible contraceptive least likely to fail because of human error—surpassing the effectiveness of even shots and implants, both of which have more side effects—it could, at long last, make a serious dent in the half of all pregnancies in the United States that are unintended.