POLL: Should more be done to make contraceptives available?
Long-Acting Reversible Contraceptives
LARC use increase since 2002 in U.S.
LARCs dispensed in Hamilton County in 2015
Decrease in Hamilton County teen pregnancies between 2006-2013
The cost for most LARCs
Shannon Fleming was sure she knew everything about birth control.
When she was in high school at Chattanooga School for the Arts and Sciences, she was a member of the Chattanooga Adolescent Awareness Team of students, which went around to other schools and taught kids about sex education.
So when a nurse at the Oxford College clinic told her she was pregnant, she refused to believe it.
"I thought I had some disease. I was so well-versed in birth control methods," said Fleming, 29, now a quality incentives consultant at BlueCross BlueShield of Tennessee. "There was absolutely no way I was pregnant."
She had been using birth control pills, and her partner had used a condom, though she conceded it had broken, Fleming said.
But she had also been taking large doses of antibiotics to fight Crohn's disease, and antibiotics can reduce the effectiveness of birth control pills, she learned too late.
Fleming graduated five months pregnant with her two-year degree from Oxford, took off a semester to give birth, and then enrolled for her final two years at Emory University in Atlanta, where she graduated with a degree in sociology. She won a fellowship to work with the U.S. Centers for Disease Control and Prevention in Chicago, moving alone with her daughter to a strange city before returning home to Chattanooga a few months ago.
"It was definitely a challenge," Fleming said. "There were some things my daughter has had to experience I didn't want her to experience. But she saw me trying and working toward something."
But Fleming is taking no chances now about letting another pregnancy get in the way of her plans. She's moved from birth control pills to an IUD contraceptive.
"They are 99.9 percent effective and last from three to five to 10 years," she said. "And they are reversible, so when you decide you want to be a mom, you can make that decision with your partner. It's a choice, not something completely unexpected that derails your life."
Fleming is not unique in her situation.
Increasingly, women are turning to longer-lasting, more effective means of birth control that are reducing the number of unwanted pregnancies, and increasing the odds that the babies they choose to have will be healthy.
Since 2002, the use of long-acting reversible contraceptives, often called LARCs, has increased more than 500 percent, from 1.2 percent among women ages 15-44 to 7.2 percent in 2011-2013, according to the CDC.
In Hamilton County, where the health department only started providing the devices in 2013, 220 LARCs were dispensed in 2014, but that jumped to 387 in 2015.
"It's changed the way we do counseling now. When women used to come in, I would start with birth control pills," said Pam Gilreath, clinic manager for adult health services at the Chattanooga-Hamilton County Health Department. "Now, if they are not planning on a pregnancy, I start with LARCs. You get the device and forget about it, and you don't have to take a pill every day."
If women listen to their doctors, LARCs should become even more widely used. More than 40 percent of gynecologists who are using birth control are using LARCs, according to Rachel Schulson, head of A Step Ahead, a local nonprofit agency that offers Hamilton County women access to long-term birth control.
LARCs are popular because they are long-lasting, often for as long as five or 10 years, and they are reversible, meaning a woman can remove them whenever she decides to get pregnant.
They come in two basic forms: IUDs that are implanted in the uterus, and implants that are inserted under the skin and slowly release a chemical that prevents pregnancy.
IUDs have been around for a long time, but they dropped dramatically in popularity in the 1970s when problems arose with one type, the Dalkon Shield, which because of its design increased the risk of infection in women. Several hundred thousand lawsuits were filed against its manufacturer, which paid millions of dollars in damages and eventually filed for bankruptcy.
IUDs today are much safer. In fact, as a result of the Dalkon Shield disaster, Congress toughened the law allowing the Food and Drug Administration to test all sorts of medical devices.
Of the four major brands, three release small amounts of the drug progestin, which prevents pregnancy by stopping ovulation. The fourth uses copper to stimulate the body's immune system to prevent pregnancy.
The other, newer form of contraception is an implant. A small container of progestin, about the size of a matchstick, is injected under a woman's skin and the chemical is slowly released over a period of up to three years.
The major disadvantage of LARCs is their upfront cost. Most range from $800-$1,000. In the long run, that is much less than purchasing birth control pills or condoms on a regular basis. But it may be too high for many women.
That's where A Step Ahead comes in.
Director Schulson emphasizes that her primary goal is not contraception, but rather to ensure unwanted pregnancies don't derail women's efforts to improve their lives by completing their educations and getting started on careers.
"When we reach a college student or a woman who is 23 and starting a career and is being pro-active and choosing a method that requires a conscious decision to have it removed — we feel we have been part of her path to success," Schulson said.
A Step Ahead operates a 24-hour phone line that women can call for information. The organization does not operate any clinics on its own, but instead refers women elsewhere, such as to the health department.
But A Step Ahead does provide funds to women who cannot afford a LARC and will arrange transportation for them to get to a clinic.
"We pay whatever is not covered" by insurance, Schulson said. Under the Affordable Care Act, all new health insurance plans offered since August 2012 must offer contraceptives at no cost to the insured.
Schulson has no medical training. She had done sex education work before she and her husband moved to Chattanooga from Dallas 19 years ago, but had not been involved in health care until she heard about a program in Memphis offering LARCs.
"I just thought, if ever a program made sense it was this one," she said. "It stays out of the debates about abortion by reaching women much farther upstream, so they are never in a position of having to make that choice and are instead being pro-active about a decision that can change the course of their life."
Long-acting contraceptives also help women space out their children, which improves the chances that their babies will be healthy. Infant mortality is 67 percent higher when women have babies less than 12 months apart, Schulson said.
"Healthy planned pregnancies give us healthy birth outcomes for both mom and baby," said the health department's Gilreath.
While no one claims LARCs should get all of the credit, their increased use is one of the reasons unwanted pregnancies have declined significantly in Hamilton County in recent years. Teen pregnancies dropped by more than 60 percent between 2006 and 2013, from 230 births down to 94.
"Lowering the teen birth rate is one of our great public health victories," Gilreath said.
For A Step Ahead, the goal is less about limiting pregnancies than controlling when they occur.
"If someone is planning their future, part of that planning is looking at when they feel the time is right for them to make the decision to become pregnant," Schulson said. "Birth control won't solve poverty or other problems, but it can open the door to opportunity."
Adds single mom Fleming, "It's letting them know their options and giving them the tools they need to craft their future the way they'd like. I'm all for that."