As an ob-gyn who specializes in pediatric and adolescent gynecology, Dr. Rupa DeSilva can trace a direct link between contraceptive access and teenagers and young adults pursuing their education.

This really does affect everyone. If a woman can plan her pregnancies and be more productive in the workforce, that trickles down to all of society. When our system is not thinking about how to provide access to teens, young adults, and women, we’re missing an opportunity.

Q: As an ob-gyn, what do you do, whom do you serve, and why do you do this work?

A. I am an ob-gyn and I have sub-specialty training in pediatric and adolescent gynecology. I’ve been practicing for 20 years. I serve my patients’ gynecological needs until age 21. How our younger generation sees themselves as people, the way they take care of themselves and participate in healthcare starts at a really young age. I hope to be a part of that for young women.

Q: What kind of barriers do women in Dallas face when it comes to getting birth control?

A. There are so many barriers. The most common ones are transportation, economics, and education. There’s also a lot of stigma around various contraceptives based on people’s values, belief sets, etc. There are clear statistics about which methods work but it’s still a personal decision that’s based on your health and the responsibilities you have.

Q: What is the single most important thing you think community leaders need to understand about the issue of contraceptive access?

A. Contraceptive access is not just a problem for low-income women. Sometimes insurance doesn’t pay for contraception. Sometimes there are barriers like taking off work for multiple different visits. That matters for low-income patients but also for many other patients. If a young adult is in school, leaving early three times to see a doctor is daunting.

Jaclyn, 30, wanted to postpone her next pregnancy in order to devote time to building her business but a lack of access to her contraceptive of choice got in the way.

“I’m going to be an at-home mom and take care of this baby. And I’m going to start my business. That’s my dream. As soon as I have this baby, I’m going to get birth control because I want to fulfill my dreams first.”

“I had two children back to back. My doctor didn’t tell me anything about birth control. I was only 21 and he wanted me to get my tubes tied. He said, hey, do you want your tubes tied, and he was trying to force me to and I said, I still want to have kids so I don’t want to get them tied this early. I didn’t want to have another baby right away. I wanted to get somewhere in life and be stable and then have more kids. So I got the pill. That’s the cheapest form of birth control. But with the pill, you can’t miss a day. I couldn’t find them one day because my boyfriend took them. I don’t know if he hid them or flushed them down the toilet but he said he wanted another baby. I understand that but he’s not the one taking care of those babies, I am.”

“Insurance finally paid for an implant. I’ve had it in my arm for five years now because it costs $200 to get it removed. That doesn’t make any bit of sense to me. Why should I have to pay them to put it in and then to take it out? Anyway I know it quit working because I’m pregnant. I’m going to be an at-home mom and take care of this baby. And I’m going to start my business. That’s my dream. As soon as I have this baby, I’m going to get birth control because I want to fulfill my dreams first. I want one more, but not right now—in three years. I can’t afford the Nexplanon or an IUD because it’s thousands of dollars. So I’m stuck.”

“You should be educated about birth control by your doctor and also in the hospital after you have a baby. I think everybody should have some type of birth control when you leave the hospital.”

Mica and her team are focused on helping ob-gyns and other women’s healthcare providers around the country get the resources needed to offer LARC immediately postpartum to women who want them.

“It is vital to remember that the U.S. has a history and current reality of discriminatory care and contraceptive coercion, including forced sterilization, which has disproportionately impacted communities of color. All contraceptive counseling and any programs aimed at increasing access to contraception, especially LARC, must be sensitive and responsive to this history.”

Q: What kind of work do you do on the Postpartum Contraceptive Access Initiative (PCAI) at the American College of Obstetricians and Gynecologists (ACOG)?

A. Through PCAI, our team prepares ob-gyns and other women’s health care providers to offer the full range of contraceptive methods to women after delivery through comprehensive, individualized training plans, including education, onsite support, and capacity building. Expanding access to the immediate postpartum initiation of effective contraception, including LARC, can empower women to choose the method that’s right for them and reduce short interval pregnancies.

Q: Why is your focus on increasing access to immediate postpartum LARC?

A. The immediate postpartum period can be a particularly favorable time to provide LARC and research shows that LARC provision is safe and effective. There are unique barriers to providing LARC that can make it challenging for health care providers and institutions to offer them routinely in the immediate postpartum setting. Our work helps to overcome those unique barriers. One benefit of increasing access to LARC immediately postpartum is that it can decrease short interval pregnancies. Short interval pregnancies, defined as pregnancy within one year of a previous delivery, are an independent risk factor for preterm delivery and adverse neonatal outcomes. Almost half of women discharged after delivery without having a desired postpartum tubal ligation will be pregnant within one year. These women know with certainty that they do not want to become pregnant and voice the need for highly effective contraception. It is a true failure of our healthcare system not to value these requests or offer another option for highly effective contraception when postpartum tubal ligation is unavailable. LARC offered immediately postpartum can serve as a bridge method for these patients after childbirth and can help support a woman’s choice of if and when she wants to get pregnant again.

Q: What are your guiding principles?

A. We believe that LARC is not the right choice for everyone and increasing access to LARC in the immediate postpartum setting is just one piece of the puzzle to ensure access to the full range of contraceptive methods whenever a patient desires it. Most importantly, we believe that women know what is best for them and their health.

Q: What barriers exist for postpartum LARC?

A. Research tells us that the biggest barrier to access for LARC immediately postpartum is the lack of insurance coverage. In most states today, significant insurance coverage gaps still exist for folks covered by Medicaid and commercial payers alike.

Q: What role can communities play?

A. Women are smart and know what is best for them and their health. The same applies to communities: communities know what’s best for them. When doing this work, it’s crucial to partner with the communities you’re trying to serve and ensure they’re at the table from beginning to end. Partnering with these communities will help ensure their voices and needs are at the center of the work.

Sherry Tenison has been a women’s health advocate for more than 20 years. She’s seen how improving education and contraceptive access can change women’s lives.

“What prompted me to open my clinic was that these women were not getting the education that they needed as it relates to their birth control, their bodies. They were not being treated in a holistic manner. I felt as though that was happening because they were low-income women. The patients were a number and not individuals.”

Q: Tell us about your job—what you do, whom you serve, and why you do it.

A. I became a women’s health nurse practitioner in 1996. From that time until now I’ve had lots of hands-on experiences in different practice settings. Some have been in Federally Qualified Health Centers (FQHCs), some in non-profits, some in private practice settings alongside MDs. So I’ve had quite a bit of experience in different types of facilities. But all of these facilities have always catered to or serviced low-income females ages 13-65.

Q: What kind of barriers do women in Dallas face when it comes to getting birth control?

A. Some of the barriers are financial. If the patient does not qualify for any type of Medicaid, then of course she’s going to go without birth control because she can’t afford to pay for it out of pocket. I have always been aware of that situation so if I had to write the patient a prescription I would always make sure I wrote it for pills on the Walmart list that are $9. A lot of my patients would say, “Oh, I can afford that.” But if they want a LARC like the IUD or implant then they wouldn’t be able to afford it because they don’t have any insurance. That’s the number one barrier to receiving birth control.

Q: What is the single most important thing you think community leaders need to understand about the issue of contraceptive access?

A. Education is a must. It’s the number one barrier that we have to overcome—to educate our patients about contraception. I want the affluent people to understand that, too. Not only should we make contraception accessible to lower-income women but we also have to make education accessible, too. Lower-income women are getting information from friends and family or YouTube versus going to their medical provider and getting the correct information about the birth control methods. Other women are able to do that without those barriers. We can’t exclude cultural beliefs about birth control methods, either. Some of those are difficult to break through as well; for example, how different cultures feel about birth control. Once again, education comes in.