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for contraceptive safety

The Population & Development Program Hampshire College

PopDev is grateful for the comments and political guidance of the feminist thinkers and activists who contributed to crafting this statement. We thank the following for their valuable thoughts and insights. We hope this statement faithfully reflects their comments, while we recognize that the details of our argument do not necessarily represent the thinking of all contributors.
Amy Allina, National Womens Health Network Jasmine Burnett, National Black Network for Reproductive Justice Marlene Gerber Fried, Civil Liberties and Public Policy Program, Hampshire College Aline Gubrium, School of Public Health & Health Sciences, UMass, Amherst Judy Norsigian, Our Bodies Ourselves Loretta Ross, activist & feminist theorist, former National Coordinator, SisterSong Kate Ryan, National Womens Health Network Sarojini N, Sama Resource Group for Women and Health Jade Sasser, Department of Womens Studies, Loyola Marymount University Marion Stevens, WISH Associates (Women in Sexual and Reproductive Rights and Health) Mia Sullivan, Civil Liberties and Public Policy Program, Hampshire College

We welcome your comments at popdev@hampshire.edu.

Betsy Hartmann, Director

Anne Hendrixson, Assistant Director

for contraceptive safety
Introduction ................................................................................ 1 Depo-Provera & HIV ..................................................................... 4 Advocating for Contraceptive Safety ............................................. 7 Call to action! .............................................................................. 9 References ................................................................................ 11

The Population & Development Program, Hampshire College 893 West Street, Amherst, MA 01002 USA 2014

are witnessing a renewed commitment to family planning on an international scale, in what some hail as a rebirth of family planning.1 Since 2009, three international conferences on family planning, as well as the 2012 London Summit on Family Planning, have served as rallying points for well-funded contraceptive campaigns, such as the partnership to promote the Sayana Press a delivery system for a form of the hormonal contraceptive Depo-Proverato millions of women in Southern Africa and South Asia. While promotions like these will create access to a limited range of contraceptive options for some, they also have the potential to pose health risks to others. Ultimately, the rebirth of family planning could undermine a more comprehensive approach to sexual and reproductive health and rights (SRHR). As strong SRHR supporters, we call for renewed advocacy for contraceptive safety. There is a proud history of activist action and cooperation to improve contraceptive safety and champion health and rights as the cornerstone of contraceptive delivery. Contraception is an important tool for womens health and rights and it should be accessible, safe, and part of general health services, along with abortion, maternal care, and HIV treatment and prevention, and a range of interventions like sexuality education.2 Now is the time to build on past successes and reinforce current efforts to promote a transformative SRHR agenda. Why is there a need for active watchdog advocacy at this time? We are concerned that as part of the so-called rebirth of family planning, prevailing approaches privilege forms of depot medroxyprogersterone acetate (DMPA), Depo-Provera.3 This is troublesome for several reasons. First, there are a number of adverse health effects associated with Depo-Provera. We believe that the serious consequences of these adverse effects on womens health make scaledup dissemination of Depo-Provera extremely questionable, if not unconscionable. We discuss this in more detail, below. Second, the privileging of Depo-Provera is an example of a larger trend in which family planning campaigns demonstrate an over-reliance on hormonal contraceptives and also certain long-acting contraceptives over other methods.4 The rationales for the mass, preferential promotion of these methods bear scrutiny. Some international agencies, national governments, and nongovernmental organizations and foundations see such methods as a technical fix for a wide range of health and development problems in the global South. This


instrumentalizes contraception as a means to achieve other international and national goals, like reducing population growth rates. For instance long-acting methods are prioritized as a favored way to reduce population growth. The Long Acting and Permanent Methods (LA/PMs) Toolkit, produced by USAID and Knowledge for Health (K4Health), states that, wider availability and use of (LA/PMs) would reduce fertility rates more than wider use of other contraceptive methods, and countries would be able to meet their fertility goals more cost-effectively.5 Family planning campaigns that focus primarily on fertility control undermine a more comprehensive SRHR approach that, for example, safeguards women against sexually transmitted infections. Methods like Depo-Provera are typically positioned as more efficiently meeting the unmet need for contraception and as a public health necessity for large numbers of target users who currently do not have access to contraception. However, the prioritizing of such methods not only constrains the range of contraceptive options made available, but narrows womens full SRHR considerations to the issue of pregnancy prevention. As such, it does not fully address the wide range of womens unmet needs in reproductive health care. Moreover, it reinforces entrenched gender roles in which women are responsible for contraception, neglecting male responsibility and contraceptive needs. Further, the arguments backing long-acting methods wrongly imply that they are primary tools for preventing maternal mortality. A family planning publication by the Bill & Melinda Gates Foundation asserts that, strengthening access to injectable contraceptives in developing countries can reduce the burden of maternal and infant mortality, while helping to ensure that both mothers and children have the opportunity for healthy, successful futures.6 However, maternal mortality occurs due to a number of diverse factors including anemia, under-nutrition, communicable diseases (including HIV), unsafe abortion, and lack of emergency services as well as larger structural social and economic inequalities, including weak health systems. It is misleading to suggest that the problem can be easily mitigated with contraceptives. As part of the argument that Depo-Provera helps prevent maternal mortality, many emphasize that it and like methods reduce unintended pregnancies and save women from undergoing unsafe abortions. Dissemination of hormonal and long-acting methods is thus promoted as a substitute for the provision of safe and accessible abortion services. For instance, a PATH promotional piece for the Sayana Press states that it nearly eliminates the incidence of unintended pregnancy and assists women in avoiding unsafely performed abortions.7

Here too the logic is flawed. No existing method of family planning is 100% effective, and even if all women used contraceptives, there would still be a need for abortion services. Women need access to abortion for a variety of reasons, including pregnancy due to contraceptive failure or incorrect use. In addition, many women discontinue contraceptive use because of adverse effects. For instance, a 2005 report of the U.S. Center for Disease Control contends that nearly 42 percent of those who take Depo-Provera discontinue use because of side effects.8 This means that women who cease to take Depo-Provera due to adverse effects may need to use a method that is less effective. The back-up of abortion services provide women with more contraceptive options. For example, women can choose a method such as the male or female condom or oral contraceptive pill with the knowledge that should the method fail, abortion is available. The suggestion that methods like the Sayana Press are an alternative to abortion has negative consequences. First, it does nothing to address or otherwise prevent unsafe practices in abortion provision or to support safe, legal and accessible abortion services. Second, it reinforces abortion stigma by suggesting that it is not the lack of safety in abortion practice that should be addressed, but the pregnancy that causes women to seek them. This undermines abortion rights advocacy. To proponents, however, forms of Depo-Provera and long-acting methods are understood as a high return on investment, credited with alleviating poverty, environmental degradation and even political instability. Viewing these methods as a technical fix for these serious global problems skews assessments of the health risks and benefits of specific contraceptive methods. When contraception is seen as a necessary response to urgent problems, a womans needs may be ranked low. Furthermore, the fact that long-acting methods are disproportionately targeted at women of color in the global South, and women of color in the U.S., raises disturbing questions about the persistence of a racialized population control agenda.

Depo- Provera & HIV

Depo-Provera has long been the subject of considerable medical controversy and resistance from feminist, human rights and anti-racist perspectives.9 Its known adverse effects include prolonged and irregular bleeding, loss of bone density in young women, significant weight gain, depression, and loss of libido. There are clear racial disparities in its use, both in the U.S. where it is mainly promoted to women of color,10 and globally where subSaharan Africa is a primary target. For example, in FY 2011, Africa received 72 percent of all USAID-funded injectable contraceptive shipments measured by dollar value.11 For over a decade now, medical studies have provided compelling evidence that Depo-Provera may increase the risk of women and their partners becoming infected with HIV. Based on research in seven African countries, a 2012 study published in the Lancet found that Depo-Provera users and their partners face a possible doubling of the risk of HIV acquisition.12 Initially, the study sent shock waves through the international family planning community;13 the South African government in particular took the findings very seriously (see below). However, rather than taking the more cautious course of phasing out DepoProvera in communities at high risk of HIV, the World Health Organization (WHO) recommended that women at risk use condoms to protect against HIV transmission and acquisition while taking Depo-Provera and similar progestin-only injectables. This recommendation could be interpreted to mean that the risk of HIV infection is viewed as a lesser evil than an unwanted pregnancy.14 Other international agencies, such as USAID, are unfortunately following WHOs lead. In fact, instead of a phase-out of Depo-Provera, the opposite is occurring. In the early 2000s, USAID invested in a public-private partnership with pharmaceutical companies to develop the Sayana Press, using the Uniject technology, a syringe-less one-shot system for vaccinations.15 Because DepoProvera is typically delivered by syringe, many African countries have refused to allow lay health workers to inject women in order to avoid the risk of unsterile needles and other problems. Pfizer worked on making Sayana Press suitable for delivering Depo-Provera subcutaneously, just beneath the skin.16 This new method is viewed as safe for lay workers to inject, and there are even suggestions that women can deliver it to themselves. The goal is to take the injection out of health clinics or the hands of health workers. This increases the probability that

women will not get appropriate counseling, information on risks, including HIV transmission, and follow-up care. In July 2012, at the London Summit on Family Planning, the Bill & Melinda Gates Foundation, USAID, the U.K. Department for International Development (DFID), UNFPA, Pfizer, and the medical non-profit PATH announced a new publicprivate partnership designed to reach three million women in sub-Saharan Africa and South Asia over the next three years with 12 million doses of the Sayana Press form of Depo-Provera. The program is organized explicitly to reduce the need for clinical services and to bring Depo-Provera to women living in some of the worlds most remote regions.17 The Gates Foundations family planning strategy is openly tied to population reduction goals; it claims that population growth significantly contributes to the global burden of disease, environmental degradation, poverty and conflict.18 This new initiative points to the dangers of a technical fix approach to contraceptive development and delivery. In communities at high risk of HIV, the promotion of Depo-Provera is questionable at best; the Sayana Press method has the additional drawback of further separating women from services that could provide HIV/AIDS prevention and treatment, as well as other reproductive health interventions, alongside contraceptive provision. WHOs dual-protection recommendation that women at risk of HIV use condoms when receiving DepoProvera is problematic as a policy prescription. It reinforces the idea that DepoProvera is safe enough when paired with condoms, rather than seriously addressing the potential for increased risk of HIV transmission by ensuring that women have access to the full range of contraceptive options and HIV prevention tools. Furthermore, studies suggest that women who employ the dual strategy of hormonal contraception for birth control and condoms for STI (sexually transmitted infection) prevention tend to use condoms less consistently than women who use only condoms. While there are complex reasons for this, the inconsistency of condom use can place women at higher risk for STIs,19 calling into question the efficaciousness of the dual protection strategy. The possible link between Depo-Provera and increased risk of HIV acquisition is a particularly serious concern in South Africa. The overall HIV prevalence in South Africa is estimated at 17.9%, with over 5.5 million people living with HIV. The highest incidence of HIV in the general population is among 1525-year-old women; over one third of young women are HIV-positive. Meanwhile, progestin injectables, primarily Depo-Provera, account for 49% of current contraceptive use nationwide in South Africa and up to 90% in some areas.20 (Another progestin injectable, Net En, has been mainly used by younger

women.) The Department of Healths new contraceptive guidelines shift the emphasis away from Depo-Provera and other injectable progestins towards alternative long-acting reversible contraceptives, such as IUDs and implants that thus far appear not to increase womens vulnerability to HIV. Acknowledging the problems with negotiating condom use, the guidelines state: For this reason it is important to recommend contraceptive methods that do not increase a womans vulnerability to HIV infection.21 Whether or not other countries will follow South Africas lead is an open question, just as it remains an open question as to how quickly the South African government will transition to other contraceptive methods not associated with a high HIV-risk. What is clear is that womens health advocates need to pay considerably more attention to the unfolding politics of Depo-Provera in subSaharan Africa, especially as the region is becoming the main target of international population reduction efforts. Even if injectables are ultimately phased out, the side effects of other long-acting methods, like implants, must be taken seriously. Troubling questions arise here: Why do long-acting methods dominate the method mix? Why isnt there more focus on the male and female condom as a contraceptive method as well as a means of preventing STIs? It is also important to challenge how international population interests are currently using high rates of maternal and infant mortality in poor regions to justify continued use of Depo-Provera. According to one recent study, the possible risks of acquiring HIV from injectable contraceptives should be balanced against other important consequences, including unintended pregnancy, which impacts maternal and infant mortality. This downplays the public health benefit of reducing Depo-Provera use. The authors support the continued promotion of Depo-Provera, with the possible exception of those countries in southern Africa with the largest HIV epidemics.22 When there are other proven ways to reduce maternal and infant mortality, and other forms of contraception available, measuring these two sets of risks against each other is deeply problematic. In the U.S., some anti-abortion forces have claimed the Depo/HIV issue as their own. Articles like Life Site Newss Melinda Gates raises $2.6 billion to give brown women Depo-Provera,23 and the American Life Leagues, Melinda Gates and Planned Parenthood targeting Africa with HIV-doubling contraception,24 argue that the Gates Foundations commitment to Depo-Provera is a population control strategy aimed at African women. They, and like-minded organizations, see this as evidence of an out-of-control sexual and reproductive health agenda that must be restricted. Silence on our part thus carries significant political risks.

Advocating for Contraceptive Safety

For over five decades, womens health activists committed to contraceptive safety have closely monitored drug regulatory agencies, the pharmaceutical industry, and family planning and population programs to insist that safety come first in the research, development and provision of contraceptive technologies. These important efforts contributed to safer formulations of the oral contraceptive pill and the IUD, and the development of new methods such as the female condom. Womens health activists also spearheaded improvements in the quality of care in family planning programs so that people would be effectively counseled on the methods most appropriate for their personal circumstances, given more options, screened for contraindications, and followed-up at regular intervals. Today the reproductive justice movement in the U.S., led by women of color, advocates for a broad agenda of bodily integrity and reproductive selfdetermination, including access to safe contraception and abortion, in the context of social, economic and human rights and community health. The fundamentalist backlash against abortion, contraception and LGBTQI25 rights, often originating in the US and exported to the global South, has made it increasingly difficult to conduct feminist advocacy on contraceptive safety. Considering that fundamentalists in the past, as well as recently, have made strategic use of feminist critiques, many womens health activists have shied away from this tricky political territory. They do not want to be seen as playing into the hands of the fundamentalists, nor do they want to be tarred with the brush of being anti-science or anti-evidence based medicine. However, engaging critically with scientific and medical research remains essential, especially in an era when there is more corporate sponsorship and less public oversight of drug trials. Assessing the evidence as well as the underlying values, assumptions, and priorities of contraceptive research is vital. Despite, or because of, the challenging political terrain, SRHR advocates should continue in a watchdog role to promote contraceptive safety in the context of overall health and well-being.

A lessening of this advocacy comes with high costs, such as:

1. Less questioning of expertise produced by vested pharmaceutical and population interests. 2. Discounting womens experiences with adverse effects. 3. The continued de-prioritizing of womens health and safety in calculations of contraceptive risks and benefits. These calculations are not neutral, and are informed by values such as costeffectiveness or the imperative to reduce population growth.26 4. Undermining support for abortion. No matter how effective in preventing pregnancy, long-acting contraceptives cannot substitute for the safety net of legal, accessible abortion services. 5. Allowing those opposed to contraception to dominate the conversation about safety denies women the highest standard of care. Women need full information about the contraceptive options available so they can make the best decisions for themselves. If we fail to advocate for that we cede the moral high ground to fundamentalists. We give support to their claim that they are motivated by concerns about womens health and rights. This allows them to appropriate the rights and justice framework in the name of defending women and girls from the dangers that have been hidden from them. Womens health activists need to be out front when it comes to contraceptive safety concerns; otherwise, we run the risk of misinformation campaigns that impact contraceptive access. 6. Lack of womens health activist involvement has meant that contraceptive programming has not assisted in crafting a culture where sexual partners negotiate method use. Instead, contraception continues to be a womans responsibility. Mens participation in family planning and reproductive health programs is often neglected. This can contribute to an entrenchment of gender roles and binaries.

Call to action!
Currently, womens health advocates face both controversy stemming from genuine questions and concerns about the safety of some contraceptive methods and controversy stemming from opposition to contraception generated by anti-choice activists who oppose contraception and abortion more broadly. Womens health advocates cant be so afraid of the latter that we dont discuss the former. The safety of Depo-Provera is only one of the current contraceptive safety issues that warrant feminist research and advocacy. The side effects of other methods bear scrutiny, as do the reasons why short-term contraceptive methods under the users control, such as oral contraceptives, emergency contraception and condoms, generally do not receive commensurate attention and support. Womens health activists must also weigh in on new methods under development. For example, the Gates Foundation is currently financing the development of a new chemical sterilization method primarily for use in India, where over-reliance on female sterilization and sterilization abuse remain endemic in the countrys population program. In the contraceptive field, it is time for the womens health movement to frame these controversies on our own terms, not those of the anti-abortion movement. We have a rich history and legacy from which to draw and new generations of activists and allies who are equal to the task.

We must work together to:

1. Act as watchdogs for contraceptive safety:
a. Evaluate scientific reports through a feminist lens b. Question expertise produced by vested pharmaceutical and population interests c. Monitor product development and dissemination schemes, including the partnerships created for these purposes d. Monitor budget flows, including foundation funding, and the resource flows from powerful partnerships e. Share analysis with others active in the SRHR, reproductive justice and public health fields and related social movements f. Challenge unsafe approaches, trials, and services through voicing feminist critiques in the media and undertaking collective action to impact policy.

2. Investigate womens complaints about adverse effects through documenting user experiences with contraceptives. Share the results with reproductive health activists and activists in other movements, as well as with policy makers and the media. 3. Champion womens health, safety and wellbeing in calculations of contraceptive risks and benefits. Challenge the idea that hormonal and long-acting methods are a technical fix for maternal mortality, environmental degradation and poverty. 4. Address HIV from a sexual and reproductive rights perspective, and address key feminist issues that arent addressed by current prevention and treatment regimes. This includes looking at why there is limited research on the best abortion methods in low resource settings in HIV endemic contexts. For example, is it better for an HIV positive woman to have a medical abortion or a surgical abortion? 5. Continue the struggle for safe, accessible abortion services and make it clear that hormonal and long-acting contraceptives are not a panacea. Stand strong with a feminist vision for comprehensive sexual and reproductive health services for all people, one that challenges both population control and conservative fundamentalist restrictions of reproductive freedom.

Richard Horton and Herbert B. Peterson, The rebirth of family planning, The Lancet, 380 A comprehensive vision for sexual and reproductive health and rights includes access to a full range of contraceptive and conceptive methods, along with complete information on their use and adverse effects, and follow-up care to address any contraindications and concerns. It includes access to safe and legal abortion, free of stigma, as well as maternal care. It means education and support on issues of sexuality, healthy relationships, and gender. SRHR services should be available and appropriate for people of all genders and sexualities as well as ages. Comprehensive care includes full incorporation of HIV treatment and prevention, as well as screening and treatment for other sexually transmitted infections. Finally, it includes accessible and quality general health care, with practitioners that view sexual and reproductive health concerns in the context of overall health. 3 Depo-Provera is one form of depot medroxyprogersterone acetate (DMPA), which Pfizer Pharmaceutical uses in several products including the Sayana Press. See PATHs fact sheet, Frequently asked questions about Sayana Press and subcutaneous DPMA, for a list of those products http://www.path.org/publications/files/RH_sayana_press_faqs.pdf (accessed March 10, 2014). 4 Long-acting methods include implants, sterilization and IUDs. While we support making long-acting contraceptives available, they should not be presented as preferable to other methods. After consideration of all appropriate contraceptive methods, a woman seeking contraception should be the one to decide which method is most appropriate and thus preferable in her situation. Each woman considering the risks and benefits of different methods will make a choice based upon her own personal circumstances and values. These choices will understandably vary, and ideally, every woman will have access to a wide range of contraceptive options in order to best meet her needs. 5 K4Health, Long Acting and Permanent Methods (LAPM) Toolkit Series Now Available!, K4Health news email (September 17, 2013). 6 The Bill & Melinda Gates Foundation, Family Planning, http://advancefamilyplanning.org/sites/default/files/resources/Family%20Planning_Sayana%2 0Press_Feb%2028.pdf (accessed February 18, 2014) 7 Lesley Reed, Putting family planning within reach, (November 5, 20013) http://www.path.org/blog/2013/11/family-planning-within-reach/. Accessed March 10, 2014). 8 Anjani Chandra, Gladys M. Martinez, William D. Mosher, Joyce C. Abma, and Jo Jones, Fertility, family planning and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth National Center for Health Statistics, Vital Health Statistics 23:25 (2005) http://www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf (accessed October 16, 2013). 9 There is a long history of national and international womens health activism on DepoProvera and other risky contraceptives. Organizations and networks that have challenged Depo include: National Black Womens Health Project, Native American Womens Health Education Resource Center, CWPE, Our Bodies, Ourselves, National Womens Health
1 2


Network, Incite, Saheli (India), Sama (India), Ubinig (Bangladesh), and Womens Global Network for Reproductive Rights. This is by no means an exhaustive list. See for instance, CWPE, Womens Health and Reproductive Technologies: Depo-Provera, http://www.cwpe.org/resources/healthrepro#Depo. 10 Thomas W. Volscho, Racism and Disparities in Womens Use of the Depo-Provera Injection in the Contemporary USA, Critical Sociology 37:5 (2011): 673-688. 11 USAID, Overview of Contraceptive and Condom Shipments, FY 2011, Washington, D.C.: KMS Project for USAID (July 2012): 7. 12 Renee Heffron et al, Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study, The Lancet 12 (Jan. 2012): 9-26. For discussion of previous studies, see Nalini Visvanathan, Hormonal Contraception and HIV Disease Acquisition: A Limited Review and Assessment of Findings, at http://popdev.hampshire.edu/sites/default/files/uploads/u4763/Visvanathan%202008.pdf 13 Pam Belluck, Contraceptive Used in Africa May Double Risk of H.I.V., The New York Times (Oct. 3, 2011) http://www.nytimes.com/2011/10/04/health/04hiv.html?pagewanted=all&_r=0 (accessed March 13, 2013). 14 WHO, Hormonal contraception and HIV: Technical Statement (Feb. 16, 2012) http://whqlibdoc.who.int/hq/2012/WHO_RHR_12.08_eng.pdf (accessed March 6, 2013). 15 J.Josepth Speidel, Steven Sinding, Duff Gillespie, Elizabeth Maguire and Margaret Neuse, Making the Case for U.S. International Planning Assistance: A Report, Baltimore: Johns Hopkins School of Public Health (January 2009): 12. 16 Sara Tift, The injection advantage: Reaching more women with an effective and convenient family planning method, http://blog.usaid.gov/2013/05/the-injection-advantagereaching-more-women-with-an-effective-and-convenient-family-planning-method/ (accessed August 28, 2013). 17 PATH, Innovative Partnership to Deliver Convenient Contraceptives to up to Three Million Women, (July 11, 2012) http://www.path.org/news/pr120711-depo-uniject.php (accessed March 6, 2013). 18 The Bill & Melinda Gates Foundation, Family Planning: Strategy Overview, (April 2012) http://docs.gatesfoundation.org/global-health/documents/family-planning-strategy.pdf (accessed on March 6, 2013). 19 Chelsea B. Polis and Kathryn M. Curtis, Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence, Lancet Infectious Diseases 13 (2013): 799. 20 National Contraception Clinical Guidelines, Department of Health, Republic of South Africa, December 2012, p. 19; also see National Contraception and Fertility Planning Policy and Service Delivery Guidelines, Department of Health, Republic of South Africa, December, 2012. 21 Ibid. 22 Ailsa R. Butler, Jennifer A. Smith, Chelsea B. Polis, Simon Gregson, David Stanton and Timothy B. Hallett, Modelling the global competing risks of a potential interaction between injectable hormonal contraception and HIV risk, AIDS 2013 27 (212): 105-113.


Ben Johnson, Melinda Gates raises $2.6 billion to give brown women Depo-Provera, (July 11, 2012) http://www.lifesitenews.com/news/melinda-gates-raises-2.6-billion-to-givebrown-women-depo-provera/ (accessed March 10, 2014). 24 American Life Leagues Stopp International, Melinda Gates and Planned Parenthood targeting Africa Back with HIV-doubling contraception, (June 27, 2012) http://www.stopp.org/wsr.php?wsr_dt=2012-06-27 (accessed March 10, 2014). 25 LGBTQI stands for lesbian, gay, bisexual, transgender, queer and intersex. 26 For a critique of the logic of cost-effectiveness, see Aline Gubrium and Amy Ferrer, Flagging An Invisible Difference in a Cost-Benefit Analysis of Depo-Provera, DifferenTakes 50 (Spring 2008) http://popdev.hampshire.edu/sites/default/files/uploads/u4763/DT%2050%20%20Gubrium%20and%20Ferrer.pdf (accessed October 13, 2013).