How cash incentives for doctors providing contraception impacts women

Unbeknownst to me, someone who admittedly knows nothing about medicine, it turns out doctors can get money for recommending certain prescriptions and treatments. This happens with a variety of fairly harmless meds, like flu vaccinations, but also with meds that can have a detrimental impact on your mental health. Namely: contraception.

As reported by The Guardian this week (September 14), in 2009, a government scheme was introduced which offered financial incentives to GP surgeries that told patients about long-acting reversible contraceptives (Larcs) – including the coil, implant, and contraceptive injection. Though the scheme was scrapped completely this year, figures show that it was linked to a fall in abortion rates, which has led many to call for the incentive to be reinstated.

A study on the scheme, published in the PLOS Medicine journal, shows that Larc prescriptions were 13 per cent higher than expected in the year 2013/14, after the introduction of cash incentives, while prescriptions for other hormonal contraceptives were 17 per cent lower. Researchers also found that abortion rates were 38 per cent lower than predicted.

Speaking to The Guardian, Dr Asha Kasliwal, the president of the Faculty of Sexual and Reproductive Healthcare, said she supports the scheme, calling it “a win-win situation for both doctors and patients”. She explained: “When GPs have more time and are rightly supported to provide information about intrauterine contraception, and contraceptive implants and injections, their patients are more likely to try these methods.”

While this may be true, it doesn’t necessarily mean that these methods are right for each individual. What the figures don’t show is how many women were subsequently recommended the wrong type of birth control, just because it benefited the GP practice.

BPAS has criticised the scheme. “The aim of a contraceptive consultation should be to provide information that enables women to decide which is the right method for her,” Katherine O’Brien, the associate director of communications and campaigns at BPAS, tells Dazed. “There is no ‘right’ method of contraception, yet sadly women have told us that they have felt pressured by their GP to choose a particular method. This damages the relationship between women and their healthcare professionals.”

O’Brien says that the idea behind the scheme – “that if more women had Larcs, there would be fewer unintended pregnancies” – is problematic in a number of ways. “Firstly, it suggests that efficacy is all that matters when it comes to contraceptives, when that is simply not the case. Efficacy is important for many women, but ultimately women want a contraceptive method that works for them.”

“There is no ‘right’ method of contraception, yet sadly women have told us that they have felt pressured by their GP to choose a particular method” – Katherine O’Brien, BPAS

“Some women will feel comfortable using a method with a lower efficacy because an unintended pregnancy – or an abortion – is something they are willing to accept on balance. And this is another reason why the Larc scheme is problematic – because it suggests an unintended pregnancy is the worst possible outcome for women, something that must be avoided at all costs.”

Earlier this month, experts asserted that progestogen-only contraceptives should be available over the counter, after a report found that many women in England are struggling to access contraception due to underfunding and cuts to services. According to The Guardian, sexual and reproductive health budgets were reduced by £81.2 million between 2015 and 2017/18, with contraceptive budgets down by £25.9 million over the same period.

Unsurprisingly, the coronavirus pandemic has exacerbated these problems, with many women unable to access their regular form of contraception during lockdown. Sales of the morning after pill dropped by half between March and April, after stay-at-home orders were imposed, proving that it’s too difficult to access and should be available without a consultation.

Speaking to Dazed, 25-year-old Taylar, who’s based in Surrey, says she was “pushed” into getting the implant at the age of 15 after enquiring about going on the pill. “I was told that it was ‘better’ because young girls have a tendency to forget to take their pill at the same time each day,” she explains. After she found that she was bleeding “constantly”, Taylor’s doctor prescribed her the pill to take on top of the implant, in an attempt to balance out her hormones.

“I was young,” Taylar continues, “but I was sure this wasn’t healthy for me. After a year, I begged for it to be taken out. At the time, not all my friends were sexually active, and my mum didn’t know I was having sex, so I was relying on doctors and nurses (for advice). They were super judgemental and didn’t listen to my concerns.”

London-based Georgie, 24, had the same experience after having the implant fitted just before starting a course of accutane to treat her acne. Although she was aware that accutane came with “serious mental health side effects”, Georgie found her “turbulent mood swings, periods of feeling down, and social anxiety” actually ramp up after she stopped taking the medication. She attributes this to the implant.

“After a year, I begged for it to be taken out. The doctors were super judgemental and didn’t listen to my concerns” – Taylar, 25

“My body didn’t ever level out in terms of my cycle,” she tells Dazed. “I was bleeding the entire time. I suffer from anaemia so my iron was so low for that year. I just felt like a tired, anxious mess!” Georgie complained to her doctor and asked to have the implant removed, only to be prescribed the pill to take alongside it. “In my head, adding more hormones was the worst thing to do. I was told to try for three to six months to see the effects. It didn’t work.”

26-year-old Ellen*, who lives in Bristol, was also advised to continue with her contraception despite complaining to the doctor. She was recommended the implant “repeatedly” by her GP before agreeing to try it. “I had a really bad experience with it,” she reveals. “Lots of bleeding, weight gain, hair growth in strange places. I was generally really unhappy.” When Ellen requested to have her implant removed after six months, the doctor said she needed to give it a year to “settle down”.

“I had to keep saying I wanted it out of my body because it was affecting my mental health before the doctor would remove it,” continues Ellen. “Learning that they receive incentives (for recommending the implant) has made me feel uncomfortable as I feel my best interests probably weren’t their priority.”

Both Ellen and Georgie have now switched to the mini pill – a daily oral contraceptive that only contains progestogen – and are finding it much more effective than long-term contraceptives.

“I feel disgusted by GPs receiving incentives,” says Milton Keynes-based Molly*, 23, who was recommended the implant in 2015 after she’d had two abortions, and had it fitted while under anaesthesia following the second termination.

“I’d already struggled with mood regulation problems and feelings of depression,” she tells Dazed, “but once I had the implant, I felt uncontrollable – like any shred of composure I had possessed before was taken from me.” Molly also found that her periods completely stopped, though she says this “wasn’t too abnormal for me being skinny and unhealthy at the time”.

After six months, Molly complained to her doctor. “Their reaction was to patronise me,” she says. “They said, and I quote, ‘We don’t usually take them out if it’s under six months because the body hasn’t got used to it yet’. I felt super trapped as if they’d told me ‘no’. I felt like because I was young, they were telling me I was wrong and that (my change in emotions were) ‘normal teenage problems’.” Molly says every healthcare practitioner she complained to “had the same dismissive reaction”.

“I’m shocked that this pushy, judgemental behaviour could be partly due to the fact that doctors can benefit from the incentive” – Molly*, 23

“Looking back now, I feel so sad that I was made to feel like an out-of-control slut for getting pregnant twice,” Molly admits. “I’m shocked that this pushy, judgemental behaviour could be partly due to the fact that doctors can benefit from the incentive.”

Georgie says the cash incentives “garner a level of distrust”, adding that she now feels “even more disorientated and misled when it comes to choosing a contraceptive that’s right for me”.

“The problem is, contraception is not a one-size-fits-all thing, so I don’t understand how they can go from recommending the pill for everyone, to now recommending the implant or coil for everyone,” asserts Ellen. “Why can’t they just give people all the info and let them decide for themselves?”

O’Brien echoes this. “The right method of contraception is the method that is right for the individual woman,” she concludes.

*Names have been changed