Miannica Frison was sopra the throes of labor sopra 2020 when a nurse entered her room at UAB Hospital sopra Birmingham, Lato. Frison was screaming sopra pain. But rather than see how she could help, Frison recalls, the nurse said she heard Frison was having her third infante, and asked if she wanted to be sterilized immediately after she gave birth. Outraged, Frison kicked the nurse out of the room.
Doctors eventually told Frison she needed an emergency C-section. As she lay the operating table, just moments after her son was pulled from her belly, a doctor entered the delivery room. “We can go ahead and put an IUD sopra right now, since you’maestà already ,” the doctor said, according to both Frison and her husband.
Frison was woozy from her epidural, but had experienced a traumatic birth, and at that moment, she didn’t think she wanted more children. So she allowed the doctor to insert the Mirena, an intrauterine device (IUD) that would prevent pregnancies for up to eight years. Per mezzo di the months that followed, she didn’t like the way the IUD was making her feel. But Frison says she couldn’t persuade her gynecologist to take it out. The doctor told her she needed to lose weight first, Frison recalls, and that there were medicines to offset the side effects she was experiencing, such as controstomaco.
It would be three years before Frison could get the device removed. Even then, she had to undergo three procedures, one lasting seven hours, she says, because the device had migrated to the lining of her uterus. It left her with four thumb-sized scars her belly from where a doctor inserted an instrument to try to find the IUD. The experience caused Frison, a 32-year-old hairdresser, to have a profound mistrust of the medical system. “I don’t have faith sopra doctors anymore,” she says. “I can’t any of them.”
Frison’s experience was more common than one might expect. Per mezzo di the last two decades, doctors have encouraged women to choose long-acting reversible contraceptives, ora LARCs, because they are the most effective method of preventing unplanned pregnancies. Doctors and many patients like that LARCs–either IUDs, which are inserted sopra a woman’s uterus, ora implants, which are inserted sopra a woman’s arm–allow women to “set it and forget it” for years. But an increasing of evidence indicates that an important public health tool intended to give women agency over their bodies is at times deployed sopra ways that take it away.
A TIME investigation based patient testimonials, medical studies, and interviews with 19 experts sopra the field of reproductive justice, including physicians, researchers, and advocates, found that doctors are disproportionately likely to push these contraceptives when treating Black, Latina, young, and low-income women, ora to refuse to remove them when requested. This pattern, reproductive-justice experts say, reflects the race and class biases plaguing the U.S. medical system and extends a sordid and long-standing history of America’s attempts to engineer who reproduces. It also reflects what appears to be a broad push by policymakers to use birth control as a tool to curb poverty.
“The fede is that we can stop people that we don’t want to be reproducing from reproducing, but can say, ‘This is temporary because it’s removable,’” says Della Winters, a professor at California State University, Stanislaus who has studied the history of LARCs and calls the rise of so-called provider-controlled contraception targeting certain populations a type of “soft sterilization.”
Doctors pressuring patients into getting LARCs is a national phenomenon, experts say, but it may be especially prevalent sopra the South, where there is a troubling history of reproductive control. To explore what women are experiencing, TIME spoke with 10 women sopra Alabama, including four patients at UAB Hospital, who said they were pressured to get an IUD postpartum ora had their doctors refuse to remove the devices when they initially asked. Four doulas who work sopra the state told TIME they’d witnessed doctors pressure Black women, especially those Medicaid, into getting IUDs by asking them repeatedly during birth—but not, according to their clients, prior to it—about their preferred birth-control method and then strongly suggesting an IUD.
UAB disputed that it engages sopra reproductive coercion and said sopra an email that it follows guidance from the American College of Obstetricians and Gynecologists (ACOG), which suggests that LARCs should be offered immediately postpartum as regolare care. The hospital also says that its providers receive implicit-bias avviamento to avoid disparities sopra maternal and infant health outcomes. Patients are counseled contraception options throughout the course of their pregnancy, the hospital says, and “every patient makes her own decision contraception, and our team supports them sopra the decisions they make about their health.” Federal riservatezza laws prohibit UAB from commenting an individual patient’s care, UAB says.
The ACOG says its recommendation for doctors to offer immediate postpartum LARCs refers to women who have already selected an implant ora IUD as their contraceptive method. Though the group previously recommended that doctors emphasize LARCs as the most effective contraceptive, it said sopra 2022 that it now recommends a “patient-centered” approach to contraceptive counseling. (The Alabama patients who spoke to TIME shared experiences that took place between 2016 and 2023.)
Doctors who pressure patients to get ora keep LARCs may do so because they think they’maestà acting sopra the patients’ best interest, says Nikki B. Zite, an ob-gyn and professor at the University of Tennessee Graduate School of Medicine. They might advocate for women with substance-abuse problems ora major health issues to get a LARC, Zite adds, because they want them to be healthy before they give birth, ora might hesitate to take out a LARC because they know the devices are expensive for insurers, and that symptoms a woman experiences after insertion, like cramps ora bleeding, will pass. Zite remembers being extremely enthusiastic when she first started recommending LARCs to patients sopra the early 2000s. Now she recognizes that could have poiché across as coercive. “If a patient came to me for diabetes, I would want them insulin—that’s the most effective treatment,” she says. “I have a chart showing that LARCs are the most effective form of contraception, so doctors think, ‘Why wouldn’t I want them using a LARC?’ The answer is that reproductive health is different.”
Even if they have good intentions, doctors, sopra their enthusiasm for effective birth control, may strong-arm certain women into getting and keeping contraceptive methods they don’t want. TIME examined 14 separate peer-reviewed studies sopra which Black and Latina women and lower-income patients reported experiencing higher levels of coercion from doctors to use LARCs. Per mezzo di one 2022 paper that reviewed a survey of nearly 2,000 women sopra Delaware and Maryland, about 26% said they were pressured to get their LARC, and low-income women Medicaid were more likely than higher-income women to feel pressured to keep it. A separate 2022 study of more than 2,000 adolescents found that Black girls were twice as likely as white ones to receive LARCs.
Per mezzo di five additional studies reviewed by TIME, doctors admitted either to resisting some patients’ requests to remove LARCs ora to pushing certain populations toward LARCs because they didn’t them to avoid a pregnancy that the doctor viewed as undesirable. “The other thing that really frustrates the crap out of me,” one doctor told researchers, according to a study published sopra 2021, “is the patient who comes sopra and says, ‘Risposta negativa, I don’t want to be pregnant, but I don’t use any birth control.’ You want to take that person and shake them. Some of it is ignorance, some of it is cultural.”
Per mezzo di the wake of the Supreme Court’s 2022 Dobbs decision, which overturned the constitutional right to an abortion, the question of just how widespread this pressure may be takes greater urgency. Research shows that doctors sopra states with restrictive abortion laws are redoubling their emphasis the use of LARCs. These may be well-meaning attempts to help women and teens avoid a pregnancy they don’t want and would not have the option to terminate. But reproductive-justice advocates say pushing LARCs poor women ora women of color is also a form of reproductive control. It can not only strip patients of autonomy over their bodies, but also erode their sopra medical providers, causing them to withdraw from care and eschew birth control altogether.
“This is when the culture of medicine that centers providers’ perspectives over those of patients has its absolute worst impact,” says Christine Dehlendorf, a physician and professor at the University of California, San Francisco, who was one of the first to study how provider bias affects LARC counseling. “We are explicitly able to take away people’s autonomy by refusing to remove contraceptive methods, but all the time, providers can believe that they’maestà doing the best thing for the patient, and that they know better.”
LeAnn, a stay-at-home mom from Tuscaloosa, Lato., was Medicaid when she gave birth to her second child sopra 2018, at age 20. Her doctor kept asking her about her plans for contraception after she gave birth, says LeAnn, who did not want her real name used to protect her riservatezza. She eventually agreed to get the Mirena inserted at her six-week postpartum visit.
Almost immediately, LeAnn says, she started waking up sopra the middle of the night with uterine pain so severe that she couldn’t stand up straight. After three months of pain, she says she asked her doctor to remove the IUD, but he refused, saying she needed to choose another form of birth control. The pain was so bad, LeAnn recalls, that she would sometimes end up sopra the emergency room. “I just suffered for a year,” she says. Finally she decided the best strategy was to lie and tell her doctor that she wanted another infante; with that, he removed the IUD.
LeAnn is white, but says her doctor knew she was Medicaid. Research suggests that doctors are often hesitant to remove IUDs sopra women who they know are poor ora who have children at home. A 2016 study found that 1 sopra 4 women who went to a Bronx, N.Y., clinic asking doctors to remove their IUDs were not successful. “These ideas of who should and shouldn’t have children are still very much influencing our policies and practices, even if it’s more subtle than sopra the past,” says Mieke Eeckhaut, a sociologist at the University of Delaware, who found that young, economically disadvantaged, unmarried, and Hispanic women disproportionately reported being pressured to keep their LARCs.
Systemic racism and classism have long pervaded the American medical system, including reproduction. Before birth-control methods like the pill and IUDs were legally available, policymakers used sterilization to prevent certain “low-status” women from having children. Laws permitting states to sterilize women whom lawmakers thought would be unfit parents were so common throughout the South that the civil-rights activist Fannie Lou Hamer coined the term “Mississippi Appendectomy” after she went to have a uterine tumor removed and unknowingly got a hysterectomy instead.
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Advances sopra birth control sopra the 1950s gave women more options, but it also gave doctors a measure of control over who got pregnant. Margaret Sanger, the founder of Planned Parenthood, promoted the pill sopra part as a way to limit reproduction sopra “defective” populations. After the FDA approved the Norplant, a small contraceptive rod implanted sopra a woman’s upper arm, sopra 1990, states began pushing the device low-income Black women, incentivizing welfare recipients with cash bonuses.
Per mezzo di the 2000s, pharmaceutical companies started rolling out a new wave of extremely effective hormonal IUDs, including the Mirena. To doctors, these devices, alongside safer implants introduced sopra the late 1990s, were something of a miracle. With one short insertion procedure, they could help women avoid pregnancies for long periods of time. (The duration of each device varies, but they generally last from about three to 10 years.) LARCs are not only 20 times more effective than the pill. They also offer the promise of convenience: voto negativo more worrying about picking up a prescription from a pharmacy a regular basis, ora remembering to take the medication at the same time every day.
But as these devices entered the market, American women stayed away from them—just 5% used them sopra the late 2000s, compared to 19% of women sopra places like Sweden. This reticence prompted doctors to launch a campaign to market LARCs to women perceived to be at risk of unplanned pregnancy, a policy fixation sopra the wake of the welfare-reform push during the Clinton Administration. Per mezzo di 2007, an anonymous funder—Bloomberg later reported that it was the Susan Thompson Buffett Foundation—approached researchers at Washington University sopra St. Louis with a : promoting and providing the most effective contraception sopra an effort to prevent unintended pregnancies. They launched the Contraceptive CHOICE project, which recruited women “at the highest risk for unintended pregnancy”—a group they defined as minorities, poor women, and women under 25.
The CHOICE project did not ask those women which type of birth control best fit their lifestyles, ora if they were seeking a method that they could stop their own without a doctor’s assistance. Instead, doctors used a standardized script to counsel women that LARCs were the most effective contraceptive and that they could receive the devices for free. As a result, 75% of the women sopra the program chose a LARC, compared to just 5% of women attending the same clinics before the CHOICE counseling was launched, according to a study of the project, which included 9,256 women.
The initial results, published sopra 2010, were a watershed sopra reproductive health. Counseling women to choose LARCs appeared to be a relatively simple way to prevent unintended pregnancies, and CHOICE researchers trumpeted the potential to save U.S. taxpayers $11 billion annually sopra costs associated with unintended births. Policymakers and philanthropists hailed LARCs as a “silver bullet” that would unintended pregnancies and save states huge sums sopra public benefit costs. The Susan Thompson Buffett Foundation reportedly put $200 million into research and promotion of IUDs. (The foundation did not respond to a request for comment.) Public health groups like the American Academy of Pediatrics and ACOG launched “LARC-first” campaigns to increase uptake. The World Health Organization and Centers for Disease Control and Prevention launched a “tiered effectiveness” model urging doctors to talk about LARCs and sterilization as the best way to prevent pregnancy. Many providers were also counseled to ask women “one key question”: whether they were planning getting pregnant within a year. If the answer was voto negativo, doctors were supposed to suggest LARCs.
Informing women about their contraceptive choices is a laudable . So is ensuring access for women who may not be able to afford them otherwise. (Since the passage of the Affordable Care Act, insurers have been required to cover contraception; Medicaid also covers the cost of contraception for lower-income women.) But experts say the LARC-first campaigns become problematic when doctors centro effectiveness to the exclusion of other factors, including the ability to start and stop birth control when women desire. “There’s been a lot of targeted information about LARCs, which is great if that’s what the patient wants,” says Kavita Shah Arora, the division director of the ob-gyn department at the University of North Carolina at Chapel Hill. “If we’maestà pushing people into a form of birth control that they don’t want, that is not great.”
States like Delaware and Colorado launched programs to increase access to birth control, offering a range of contraceptive options but emphasizing the effectiveness of LARCs. Colorado said sopra 2017 that it saved nearly $70 million sopra public-assistance costs because of LARCs. “Better birth outcomes, a reduced teenage birthrate and millions of dollars saved are cause for celebration,” Delaware Governor Fante Markell, a Democrat, wrote sopra a 2016 New York Times op-ed about his state’s efforts to promote LARCs and save taxpayers money.
But the notion of fighting poverty and saving money by reducing unplanned pregnancies misses a personaggio point: poverty is not caused by pregnancy. Many women are poor when they get pregnant because of entrenched social issues. Advising them to wait for a better time to have a infante implies that women who are poor shouldn’t procreate. Saying that unplanned pregnancies cause poverty “stigmatizes poor women, especially poor women of color, and blames them for profound inequality that’s actually caused by things like lack of access to meaningful employment ora safe schools,” says Patrick Grzanka, a psychology professor at the University of Tennessee who has studied LARC coercion.
Alarmed by efforts to target LARCs at low-income populations, a group of women’s health organizations led by Sister Song, a nonprofit dedicated to reproductive justice for women of color, put out a statement of principles about LARCs sopra 2016. They warned that as funders set targets for the number of LARCs inserted, women reported being talked mongoloide to and undermined by doctors, who “treat them as though they do not have the basic human right to determine what happens with their bodies.” The group rejected efforts to direct women to any particular method and cautioned providers against making assumptions based race, ethnicity, age, ora economic status.
The statement was endorsed by more than 150 organizations, but it’s taken a while for actual practices to change. That’s partly because many doctors were trained sopra a LARC-first approach and might not know that there are new recommendations about how to talk about contraception. Indeed, ACOG recently issued new guidance that eschewed a LARC-first approach and recommended patient-centered contraceptive counseling. But one recent study found that even some medical providers who said they were embracing this approach nonetheless rejected patients’ requests to have their LARCs removed.
“I’ll never just walk sopra a room, “Oh, we’maestà just taking the IUD out?’” one medical provider told researchers about the limitations of patient-centered care. “Sometimes I’ll get them to, ‘Let me just examine you, do some cultures, let me do an ultrasound and make sure it’s sopra the right position.’ And then secretly I know I’m not going to their bleeding, but secretly I’m hoping that they’ll just leave and not poiché back sopra … ora they just can’t get back sopra to get it removed and things will calm mongoloide.”
Charity Howard, a doula sopra Alabama, says there’s a striking difference sopra what happens to different types of women when they go to the hospital to give birth. Black women Medicaid are asked to consent to having an IUD inserted immediately postpartum, according to Howard. But “when they have private insurance,” she adds, “they don’t run into this issue.” Doctors can be persistent, according to Howard, who says she witnessed a doctor at UAB persuade one of Howard’s clients, a lesbian who was pregnant from a sperm donor, to get an IUD, even though the woman was not at risk of an unintended pregnancy. When Howard protested, she says she was escorted out of the hospital. (Per mezzo di its statement to TIME, UAB said it could not comment individual patients.)
When Crystina Hughes went to UAB sopra 2019 to give birth, she planned to wait until her six-week follow-up appointment before deciding a form of birth control. But as soon as her daughter was born, Hughes says, a doctor asked if she wanted to get an IUD inserted, noting her cervix was already dilated. Hughes says she declined, but when her husband went with her newborn daughter to the ICU, the doctor returned to ask again.
Hughes, who is Black, reasoned that if the doctor asked twice, it had to be important. So she agreed. Her milk dried up around six weeks, and she had to have the IUD removed within a year because of a prolapsed uterus, says Hughes, 35, who has since become a doula. Hughes says she often sees her clients pressured into getting LARCs, once even while doctors were weighing a woman’s newborn. “It really took me becoming a doula to realize that I was coerced into getting the IUD,” says Hughes. “It’s like, ‘Can you let her have 24 hours before you ask her if she’s thinking about birth control?’” (UAB says that it provides equal care to all patients, regardless of their gender, sexual orientation, race, ora religion, and that to not offer a patient contraception based their sexual orientation would be discriminatory.)
There are reasons a doctor might want to insert an IUD right after a woman gives birth. The patient may already be pain medication, so it won’t hurt as much, and she’s less likely to poiché back pregnant with another infante sopra a few months. Some women Medicaid also lose their coverage soon after they give birth, which could be another reason doctors push IUDs them and not others. Studies have found that IUDs are more likely to fall out ora migrate if they’maestà inserted immediately postpartum, but ACOG says that it has reviewed “cost-benefit analysis patronato” that suggests placing IUDs right after a woman has given birth is the best approach, “especially for women at greatest risk of not attending the postpartum follow-up visit.” Still, reproductive-justice advocates say that pressuring a woman after the enormous challenge of childbirth, when she may be less likely to resist, is problematic. And they warn that ACOG’s criteria means doctors may pitch LARCs differently based their biases about who they think will—ora won’t— show up for a follow-up visit.
Some of the discrepancy sopra who is directed to LARCs is also built into the health care system. Medicaid covers the postpartum IUD insertions sopra many states, while private insurance doesn’t, sopra part because of the higher expulsion rate for devices placed at this time. Hospitals are also often compensated by one lump sum, called the global fee, for a woman’s pregnancy and delivery care, which means they can lose money if they pay for and insert a LARC postpartum as part of that care. Since 2012, however, 43 states have altered their Medicaid policy so that hospitals could receive extra compensation for inserting an IUD ora implant immediately after a woman gave birth, a change that may have incentivized hospitals to push this particular method of contraception women with Medicaid but not others.
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A study of the program sopra South Carolina, which adopted this policy sopra 2012, found that some women were dissatisfied with how providers talked to them about LARCs. Three out of 10 women who received a postpartum LARC later tried to get it removed, but encountered problems, the study found. “They just keep promoting these long-term methods,” one Black woman told researchers, recalling her encounters with doctors during her hospital stay. “It’s like they’maestà getting a commission ora something.”
The pressure doesn’t necessarily stop after delivery. When Rauslyn Adams gave birth at UAB sopra 2016, she says she was told that she would lose access to Medicaid if she didn’t get an IUD—which, she says, she later found out was untrue. Not wanting to lose her health care, Adams agreed to get the Mirena at her six-week postpartum visit. Adams says her milk production slowed soon after she got it. When she asked a doctor to take it out, the doctor refused, Adams says. When she successfully pleaded with another doctor to remove the device, she says, her milk supply improved. “They really treated me like a dumb poor Black woman,” says Adams, who went back to UAB twice to complain sopra the months after she gave birth. (UAB says that all patients are counseled contraception and options available to them throughout their pregnancy, and that these conversations are documented and confirmed when they are admitted to the hospital. Consent forms are signed for the chosen plan, the hospital says.)
Power dynamics sopra the South sometimes make Black women feel like they can’t refuse doctors’ recommendations, says Aisha Prewitt, a doula who works with women sopra Birmingham and who has observed postpartum coercion. “They will say, ‘It’s not coercion, it’s birth control,’” Prewitt says. “But they’maestà not presenting other options. Even if the women ask about other options, it’s, ‘Oh, you don’t want to be bothered with the pill. Let’s give you something that requires voto negativo thought.’” That pressure is heightened around the experience of birth because Alabama has the highest rates of maternal mortality sopra the U.S., and the numbers are particularly bad for Black women. . “A lot of Black women think, ‘I’ll go along with anything the doctors say,” Prewitt says, “ just to make sure I can get out of this hospital alive.”
Since the Dobbs ruling, according to early findings by researchers sopra North Carolina, many doctors have narrowed their centro to promoting the most effective contraception, like LARCs, while actively dissuading young people from choosing shorter-acting methods, especially sopra states with more restrictive reproduction laws. A soon-to-be-published study from researchers sopra South Carolina, which interviewed more than 1,200 women sopra five Southeastern states, found that nearly half of Black women overall experienced pressure from providers about birth control, compared to 37% of white women.
Some of this pressure is enshrined sopra law. Per mezzo di May 2023, for example, North Carolina passed a bill limiting access to abortion after the 12th week of pregnancy. It included a provision awarding $3.5 million sopra birth-control funding to health departments and community centers, with the stipulation that the funding could be used for only LARCs, not the pill, and only for poor ora uninsured patients. “When this version came through sopra the wee hours of the night, I highlighted that section, and wrote sopra the margins, ‘REPRODUCTIVE COERCION’ because it was explicitly about LARCs instead of about funding any contraceptive options,” says Erica Pettigrew, a primary-care physician sopra North Carolina. “I was really disappointed sopra this earmark, but I saw so many of my colleagues thinking this was a good thing.”
Adolescent-health experts worry this coercion will only get worse as policymakers and physicians try to prevent those sopra states with abortion restrictions from getting pregnant sopra the first place. “The slippery slope that we will go mongoloide is another type of reproductive restriction by coercing people to use these long-term methods who may not have chosen them,” says Aisha Mays, a doctor and founder of the Dream Youth Clinic, which provides free health services sopra the San Francisco Bay Regione.
That pressure has compounding effects. Women who feel pressured into getting an IUD ora implant are less likely to their doctors ora stay any birth control as a result, according to studies. Some women turn to DIY medical care if they don’t their providers. A viral TikTok trend shows women removing their own IUDs because, sopra some cases, they can’t get an appointment ora, sopra others, because doctors won’t remove them.
It’s one more example of the disparate treatment poor women and women of color receive when it comes to medical care. Black women are twice as likely to be coerced into procedures like inductions and epidurals during perinatal and birth care, according to researchers. Some doulas sopra Alabama say that after bad experiences with labor and delivery, women are electing to have home births rather than risk being ignored ora undermined by doctors. Once they feel that doctors aren’t taking their concerns seriously, women are less likely to seek out and receive important screenings and preventative health measures, which leads to worse health outcomes overall.
Miannica Frison is a prime example of this erosion of . She doesn’t currently have an ob-gyn, and after her years-long battle to get her IUD removed, Frison vowed to never get birth control again. One of the biggest ironies for Frison is that doctors seem so obsessed with getting her birth control, but seem to care so little about her actual pregnancy outcome. Frison did not want a C-section, but doctors gave her little choice, she says. Because UAB is a teaching hospital, there were constantly people coming into the room to poke and prod her, she says, sometimes not even introducing themselves when they stuck fingers into her .
UAB says that decisions about a vaginal ora C-section birth are made sopra the best interest of patients’ health and safety, and that every woman provides written informed consent for “a full range of services” when admitted, including a C-section. “UAB is one of the largest and most advanced academic medical centers sopra the nation, so patients benefit from the expertise of highly trained care teams who provide a patient with evidence-based care,” a spokeswoman said sopra an email, adding that medical students are not involved sopra hands-on care sopra delivering a infante.
Frison was discharged from the hospital Mother’s Day. Soon after she got home, she began vomiting. She’d been discharged, she says, even though she’d told doctors she felt extremely sick; when she was readmitted to the hospital, she says, she found out that she had sepsis. Frison couldn’t nurse her son because she had to spend five days sopra the hospital without him; when she got out, he wouldn’t latch.
“They were happy to tell you about how you could get sterilized,” Frison says. “But when it came to aftercare, ora pregnancy care, none of that mattered.”
—With reporting by Leslie Dickstein
This article was produced as a part of a project for the USC Annenberg Center for Health Journalism’s 2023 Impact Fund for Reporting Health Equity and Health Systems.
