Miannica Frison was in labor in 2020 when a nurse entered her room at UAB Hospital in Birmingham, Ala. Frison was screaming in pain. However, rather than see how she could help, Frison recalls the nurse said she heard Frison was having her third baby, 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 on 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 in right now, since you’re already open,” 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. In 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 nausea.
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 on 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 in doctors anymore,” she says. “I can’t trust any of them.”
Frison’s experience was more common than one might expect. In the last two decades, doctors have encouraged women to choose long-acting reversible contraceptives, or LARCs, because they are the most effective method of preventing unplanned pregnancies. Doctors and many patients like that LARCs–either IUDs, which are inserted in a woman’s uterus, or implants, which are inserted in a woman’s arm–allow women to “” for years. But an increasing body of evidence indicates that an important public health tool intended to give women agency over their bodies is at times deployed in ways that take it away.
A TIME investigation based on patient testimonials, medical studies, and interviews with 19 experts in 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, or 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 idea 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 in the South, where there is a troubling history of reproductive control. To explore what women are experiencing, TIME spoke with 10 women in Alabama, including four patients at UAB Hospital, who said they were pressured to get an IUD postpartum or had their doctors refuse to remove the devices when they initially asked. Four doulas who work in the state told TIME they’d witnessed doctors pressure Black women, especially those on 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 in reproductive coercion and said in 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 standard care. The hospital also says that its providers to avoid disparities in maternal and infant health outcomes. Patients are counseled on contraception options throughout the course of their pregnancy, the hospital says, and “every patient makes her own decision on contraception, and our team supports them in the decisions they make about their health.” Federal privacy laws prohibit UAB from commenting on 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 or IUD as their contraceptive method. Though the group previously recommended that doctors as the most effective contraceptive, it 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 or keep LARCs may do so because they think they’re acting in 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 or major health issues to get a LARC, Zite adds, because they want them to be healthy before they give birth, or 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 or bleeding, will pass. Zite remembers being extremely enthusiastic when she first started recommending LARCs to patients in the early 2000s. Now she recognizes that could have come across as coercive. “If a patient came to me for diabetes, I would want them on 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, in 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 in which Black and Latina women and lower-income patients reported experiencing higher levels of coercion from doctors to use LARCs. In one 2022 paper that reviewed a of nearly 2,000 women in Delaware and Maryland, about 26% said they were pressured to get their LARC, and low-income women on Medicaid were more likely than higher-income women to feel pressured to keep it. A of more than 2,000 adolescents found that Black girls were twice as likely as white ones to receive LARCs.
In five additional studies reviewed by TIME, doctors admitted either to resisting some patients’ requests to remove LARCs or to pushing certain populations toward LARCs because they didn’t trust 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 , “is the patient who comes in and says, ‘No, 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.”
In the wake of the , which overturned the constitutional right to an abortion, the question of just how widespread this pressure may be takes on greater u
