Reading the fine print in North Carolina's new abortion law

By Lisa Levenstein and Justina Licata

In May, when Republicans passed new restrictions on abortion access, they assured North Carolinians that Senate Bill 20 was a “common-sense, reasonable” bill that provided “needed support for women and families” such as expanding access to birth control. House Speaker Tim Moore praised the bill for taking a “holistic” approach that included funding for health care, foster care, adoption, and contraception. 

But reading the fine print suggests there is nothing reasonable about SB 20’s approach to contraception. The bill’s only mention of contraception is in Section 4.1, which awards $3.5 million in recurring funds to local health departments and community centers “to purchase and make available long-acting reversible contraceptives for underserved, uninsured, or medically indigent patients.” Like its abortion restrictions, SB 20’s birth control provision places limitations on women’s reproductive choices.

Why is the state only subsidizing “long-acting reversible contraceptives,” known as LARCs, which include IUDs, like Mirena, and implantable birth control devices, like Nexplanon? Why not fund other forms of contraception like birth control pills for the “underserved, uninsured, or medically indigent”? 

The recent history of Long-Acting Reversible Contraceptives (LARCs) points to some answers to these questions. 

Over the past thirty years, physicians and policy makers have relied on LARCS to enact coercive temporary sterilization policies and practices targeted at low-income women. The rhetoric that has accompanied such policies often portrays these women taking advantage of the welfare system and as incapable and unworthy of making their own reproductive choices. 

Lawmakers and physicians have directed low-income women to LARCs rather than other forms of birth control because LARCs are highly effective and provider-controlled, meaning a healthcare practitioner or the government can override a patient’s decision to stop using the drug. 

With a patient-controlled method of contraception like the birth control pill, if a person no longer wants to take it, they simply stop. They can decide to use the pill for a while, then switch to another patient-controlled method like a NuvaRing. Although patients typically need to see a doctor and get a prescription to access such methods, the choice of whether to continue using them is theirs. With a provider-controlled method, like an IUD or implant, if patients want to stop using it, they must get and pay for an appointment with a healthcare provider willing to remove it. Until they get the doctor’s approval and assistance, they must continue using the method, even if they no longer want to have the IUD or implant in their bodies. 

The battles over the first subdermal implantable contraceptive device, Norplant, offer a recent example of how physicians and lawmakers have pressured low-income women to use LARCs and refused to honor patients’ requests to remove them. Norplant, which consisted of six silicon rubber rods filled with the man-made hormone progestin, prevented pregnancies for up to five years when inserted under the skin of a patient’s upper arm. In December 1990, when the FDA approved the Norplant device, many U.S. doctors and feminists hailed it as a significant step forward in their reproductive freedom. But some women of color and reproductive justice activists warned that provider-controlled drugs “had been used to coercively sterilize vulnerable people” in countries like Bangladesh. Within months their predictions began playing out as U.S. judges, lawmakers, and community leaders pressured poor women, particularly Black, Indigenous, and other women of color, to use Norplant.

Almost immediately, state lawmakers proposed policies either requiring women on welfare to be implanted with Norplant or providing monetary incentives to welfare recipients who agreed to use the contraceptive implant. In North Carolina, they proposed a 1993 bill that would have required women receiving state-funded abortions to have Norplant implanted. 

While these coercive measures did not pass, every state’s Medicaid program agreed to pay for a recipient’s Norplant device and insertion. Like SB 20, such policies gave many low-income women access to the LARC. But Medicaid recipients interested in other forms of contraceptives had to pay for those prescriptions —and most patients could not afford them. Particularly troubling, when patients reported some of the alarming array of side effects caused by Norplant—from severe cramping, infections, and irregular and sometimes constant bleeding to migraines, significant weight gain, dizziness, depression, and fatigue—they struggled to convince healthcare providers to remove the device. Instead of removal, healthcare practitioners often tried treating their painful symptoms with estrogen or even other birth control pills.

While all state’s Medicaid programs covered the cost of Norplant’s insertion, many did not pay for the removal, especially if a patient requested it before the five-year period. Such violations of bodily autonomy, which were essentially forced temporary sterilizations, made women endure physically painful side effects compounded by the stress of having an unwanted device in their body.

While physicians promise that today’s LARCs are safer than Norplant, all hormonal birth control methods have contraindications that could lead to life-threatening side effects, including blood clots and strokes. Further, it remains impossible to predict which contraceptive will work best for a person. Many people need to try a few different methods before settling on the one that best suits them—and their decisions often change over time. Since low-income and uninsured women can’t afford contraception without government assistance, by steering them to LARCs, SB 20 robs them of the ability to exercise their full range of reproductive choice. 

There is nothing common sense about restricting North Carolinians’ ability to control their bodies and inflicting specific constraints on those most vulnerable. No wonder Republicans rammed SB 20 through in 48 hours—less than the waiting period the state wants to mandate for women to obtain an abortion pill after an in-person consultation. 

North Carolinians deserve lawmakers who have learned from our state’s sordid history of eugenic practices that sterilized over 7,600, mostly African American, residents. In face of this track record, politicians should be exercising supreme caution in passing any legislation that restricts women’s reproductive choices and interferes with their bodily autonomy. Section 4.1 suggests that today’s Republican politicians have only become more sinister in their efforts to control the reproduction of low-income women. 

Lisa Levenstein is Professor of History and Director of the Women's, Gender, and Sexuality Studies Program at UNC Greensboro. Justina Licata is Assistant Professor of History at Indiana East University and is writing a book on the history of Norplant.