Dundee, the city with the highest rate of drug deaths in Europe, is the first place in Scotland to deliver the Pause intervention to 20 women from some of the city’s poorest areas. The programme, which started in England, offers support to women who use drugs on the condition that they receive long-acting reversible contraception (LARC), including implants, injections and intrauterine devices – the pill is not an option. These LARCs are administered by healthcare professionals and don’t require – or allow – the woman to do anything.
An independent report on Pause states that: “As a condition of beginning this voluntary programme women agree to use an effective form of reversible contraceptive for the 18-month duration.” The aim is to give women the chance to “pause” and take control of their lives. In the Dundee Pause programme, LARC use is required for women to proceed beyond the first four months of the programme.
However, the very heart of the intervention – the condition that the woman uses a long-acting reversible contraceptive – is highly contentious. As two academics with experience in researching women who use drugs and who have significant other health and social challenges, we want to raise questions about the use of conditions when it comes to women’s reproductive rights in these kinds of programmes.
Incentives and conditions
Undoubtedly, LARCs have provided women with valuable new birth control options. LARCs are highly effective compared with other methods, such as the pill, and can be seen as helping women who wish to prevent pregnancy but cannot shoulder the responsibility of making decisions about contraceptive use. Yet, because LARCs depend on the provider, they can also be problematic since they effectively involve the women relinquishing any control over their fertility – some forms of LARC last up to 10 years.
Critics have argued this denies women agency and renders them objects of social surveillance by providers of sexual and reproductive healthservices. In the US, research has reported on cases where doctors resisted requests, or refused to remove, intrauterine devices when a woman asked for it to be done.
Questions have also been raised by academics and practitioners regarding public health campaigns that have moved beyond ensuring access to LARCs for all women, to promoting LARCs to small numbers of women deemed at “high risk” of unplanned pregnancy. Research has highlighted racial and socioeconomic disparities in LARC use by demonstrating that women who are poor, less educated or from black and minority ethnic groups were more likely to use them.
Based on such findings, LARCs have been criticised as being implicated in state and medical interventions where racism, poverty and sexism intersect, resulting in serious violations of women’s autonomy. Reproductive health analyst Rachel Benson Gold examined US proposals to provide financial assistance on the condition that women agree to use LARCs. And in a paper on disparities in women’s use of the Depo-Provera injection in the US, sociologist Thomas Volscho uses the term “sterilisation racism” when highlighting the potential of LARCs to be used as a punitive, racially targeted population control measure.
LARCs and women with problematic drug use
Women who use drugs are commonly regarded as both “at risk” and “risky”. The media often portray women who use drugs and get pregnant as undeserving mothers. Maternal drug use is routinely associated with words such as “abuse” or “kill”, and pregnant women who use drugs are portrayed in the media as “lethal foetal containers”, for which the American sociologist Jaber Gubrium coined “the mother-as-monster image”.
Designated a risk to themselves, their children and their unborn babies, and society in general, it should come as no surprise that the reproductive capacity of women who use drugs has been at the forefront of policy and practice concerns. In the US, women have been subjected to criminal prosecution for using drugs during pregnancy. In Scotland, in 2006, a Scottish MSP suggested “putting some form of oral contraception in methadone” during a parliamentary debate at Holyrood.
LARCs are featuring more and more in interventions involving women who use drugs as an effective and beneficial way to address the unmet need for contraception, with suggestions of “nudging” them towards its use. But such practices have been accused of preventing women from exercising agency. A prime example is Project Prevention in the US, which “incentivises” people who use drugs to either get long-term birth control or get sterilised in exchange for money.
Researchers have condemned Project Prevention, highlighting that paying women to limit or stop their ability to have children is coercive, infringes on their rights and freedoms, and constitutes population control. “Nudging” can be even more explicit: in the US, there have been suggestions of forced LARC implantation for women who show signs of substance use during pregnancy.
Pause: a slippery slope?
Pause in Dundee does not provide financial incentives to women who use drugs in exchange for agreeing to use LARCs. It does, though, attach strings to offers of support and treatment to women who have experienced, or who are at risk of their children being taken away. Undoubtedly, access to contraception may help women to control their fertility and is essential to ensuring they are involved in decisions about their own bodies.
But shouldn’t treatment and support for those with problematic drug use be provided to all those that need them? Is it ethical to attach conditions to providing support that public services are already expected to deliver? And what could follow next?
We should not ignore the many examples throughout history, such as the forced sterilisations of HIV positive women throughout the world. There seems to be a fine line between “supporting” women in their reproductive decisions and forcing them to control their fertility. It could be a slippery slope to something far more disturbing.