Contraceptive implants and IUDs are very effective in preventing pregnancy — nearly 100 percent, statistics show. A new federal survey finds many more women are making this choice than did a decade ago.

Federal researchers analyzed data from a national health survey which included birth control practices among women of childbearing age. The survey found that while use of the pill, condoms, and female sterilization all dipped between 2002 and 2013, the number of women using long-acting contraception more than quadrupled. These days, 11.6 percent of U.S. women — 4.4 million — rely on either an intrauterine device or a contraceptive implant to prevent pregnancy.

The IUD is a small coil inserted into the uterus to block contraception, either by disrupting sperm mobility or releasing a hormone that inhibits ovulation. The implant works by releasing the same hormone, this time delivered via a small, flexible tube inserted under the skin, usually in the woman’s upper arm.

Both methods are reliable for years without intervention or replacement, doctors say, and that’s key to their efficacy and popularity. The implant prevents pregnancy for 3 years and the IUD for 3 to 12 years, depending on the type, says Megan Kavanaugh, Senior Research Scientist at the Guttmacher Institute. The pill is also highly effective, when taken as prescribed every day, she says, but you have to remember to take it.

Kavanaugh says the methods are endorsed as good options by medical associations, and more and more providers are being trained in how to insert them, which may have contributed to the uptick in use. Also, in plans established under the Affordable Care Act, insurance companies are required to cover birth control methods, including inserting IUDs and implants, she says. And that could increase their popularity.

As part of her own research on why women choose one method of birth control over another, Kavanaugh interviewed teenagers and young 20-somethings. Many, she says, told her, “I have so much on my plate — and I can’t remember to take a pill every day.” For this age group in particular, Kavanaugh says, these long-lasting methods are very reasonable options. They’re the most effective methods available, she adds, “similar to sterilization” in effectiveness.

Unlike sterilization, the IUD and implant are both reversible and can be stopped at any time — also an important consideration for many people.

“We just want to have as broad a mix as possible for all women,” Kavanaugh says, “so they can choose the birth control method that works best for them.”

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For Linnea Duvall, a marriage and family therapist who lives and works in Santa Monica, Calif., the symptoms of menopause started when she turned 50. She felt more irritable, a smidge heavier and she started waking up two to three times a night.

And then she had a hot flash.

“It felt like a nuclear bomb went off right behind my belly button,” she says. “The radiation went out to my fingertips, the tops of my toes, the top of my head and the ends of my hair.”

But Duvall would not consider hormone therapy to control the flashes. She was terrified. She says she can sum up her fear in two words: “breast cancer.”

To understand why she feels this way, we have to look back a few decades to a time when many postmenopausal women were taking hormones to treat symptoms. At the time, hormones were thought of as something of an elixir of youth that could also prevent chronic disease. So women took hormones indefinitely. But a huge study in 2002 changed everything.

Known as the Women’s Health Initiative, it found that taking estrogen plus progestin hormone replacement therapy actually increased a woman’s risk of heart disease and breast cancer. The study had a huge effect. Within months the number of women taking hormones in the U.S. dropped by almost half. Today, only about 10 percent of women aged 50 or over are on hormone therapy.

That was a huge overreaction, according to Dr. Wulf Utian, director of the North American Menopause Society, particularly in light of more recent findings. A more detailed analysis of the Women’s Health Initiative data found that age really made a difference in heart disease risk. For women who started hormone therapy between the ages of 50 and 59, there was a protective benefit, says Dr. JoAnn Manson, one of the lead investigators of the study and a professor of medicine at the Harvard T.H. Chan School of Public Health.

Women who take hormones earlier after the onset of menopause may experience less plaque, blood vessel blockage, and atherosclerosis, Manson says, “And possibly even a reduced risk of heart attack. But for women over the age of 60 the benefit seems to disappear. This is probably because older women already have plaque buildup, Manson says.

Researchers in Denmark also found that age makes a difference. They looked at 1,000 healthy women between the ages of 45 and 58. The women who took hormones experienced significantly reduced risk of mortality, heart failure and heart attack.

Today, menopausal women are young in the scale of things, says Dr. Wulf Utian, noting that menopause typically starts between age 45 and 60. If women start hormones within in a few years of menopause or even a few years before, he says there are numerous benefits beyond controlling hot flashes. These benefits include reduced risk of bone fractures, reduced risk of diabetes and for many women, an overall boost in their quality of life — meaning better sleep, maintenance of libido and more comfortable sex.

“In my opinion, the best recommendation would be for some form of hormone therapy,” says Utian.

But here’s the worry. Studies do confirm an increased risk of breast cancer among women taking hormones, regardless of age. Manson says any risk is worrisome, but it’s important to put this risk in perspective and understand that it is actually small.

“For every 1,000 women per year not using hormone therapy about 3 would develop breast cancer,” Manson says. “And among every 1,000 women using hormone therapy about 4 of them would develop breast cancer, so that’s about 1 extra case of breast cancer per 1,000 women per year on hormone therapy.”

This is where things get tricky. There is no consensus in the medical community on whether the symptom relief is worth the extra risk. Different doctors interpret risk differently. And if you’re a breast oncologist like Dr. Rowan Chlebowski at Harbor UCLA Medical Center, any risk is too much.

“It’s a disease that I see every day,” Chlebowsi says. “So I think that’s something to be avoided.”

Chlebowski adds that hormone therapy also makes it more difficult to read mammograms, since hormones make the breast denser. If mammograms are more difficult to read, it’s harder to diagnose breast cancer in its earliest stage when it’s most treatable.

So bottom line — this really is an individual decision between a woman and her doctor, a decision based on how much risk a woman can tolerate in favor of symptom control and other potential benefits. Researcher Joann Manson says if a woman chooses hormone therapy, then the lowest possible dose for the shortest amount of time is probably safe for most women.

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Dr. Roberta Miller hits the road at 8 a.m. to see her patients.

Many are too old or sick to go to the doctor. So the doctor comes to them.

She’s put 250,000 miles on her Honda minivan going to their homes in upstate New York. Home visits make a different kind of care possible.

“You can evaluate the person as a whole,” says Miller, who has been a home care physician in Schenectady, N.Y., for more than 20 years. “You see everything that influences their health and well-being: the environment, the surrounding people, the support system, whether they had or didn’t have food.”

Miller spends about an hour at each house call. Conversation with patients and their family members flows so naturally that it’s easy to miss that she’s also checking vital signs, gently stretching a hand, noting which pill bottles are empty.

Although Miller’s practice may harken back to the country doctor of decades past, it could be the future of medicine. In 2013, about 2.6 million Medicare claims were filed for patient home visits and house calls. That’s up from 2.3 million visits in 2009 and 1.4 million visits in 1999, according to Medicare statistics.

The trend is expected to accelerate as baby boomers grow older. One in 20 people over the age of 65 is homebound in the U.S., according to a study published in July in JAMA Internal Medicine.

“That’s just the nature of the population we treat,” Miller says. “They’re extremely ill. Homebound patients often have up to 12 or 13 problems, not just one.”

And they’re often invisible. These people could be living just down the block, and you’d never know it. Many of them never leave their homes.

Miller’s patients include a 55-year-old woman with ALS who can communicate only with her eyes, a 27-year-old former quarterback left quadriplegic after surgery on an Achilles tendon, a 92-year-old woman cared for by her daughter and a severely depressed man who lives alone.

It’s challenging to visit one patient after another, many of whom are at the end of the line, Miller says. What helps keep her going is the deep relationships that develop, where she acts as family, friend and physician.

“Many times, like this gentleman, he’s all alone. You are it — you are the contact. And in that sense, sometimes it’s overwhelming,” Miller says after visiting a patient who has no family nearby. “You have to set limits, and when you do that, you can have a really excellent working relationship with people.”

Being on-call for her patients 24/7 can be a challenge, but Miller feels responsible, knowing there are so few home care doctors out there. She and her husband, Dr. David Hornick, who’s also a home care physician, have close to 300 patients right now. There’s a long waiting list for care.

There aren’t enough home care doctors to go around. One reason is reimbursement. “Health care systems are attracting primary care providers to their networks by salary packages that can’t currently be sustained in a home care practice,” Miller explains.

Home care skills are rarely taught in today’s medical education system, Miller says, but that doesn’t mean there’s not a need.

After the Affordable Care Act took effect in 2014, Miller saw a spike in new patient requests. Low-income Medicaid patients had sought house calls in the past, but the government insurance wasn’t enough to cover the cost of Miller’s visits, including travel expenses.

“Now we can afford to see them and take care of them. Because they haven’t had medical care, they have multiple medical needs and psychosocial needs,” she says. “It has given us access to a group of people, but more importantly, they have access to us.”

The Affordable Care Act affected Medicare patient coverage, too, Miller says. Medicare reimbursements increased in 2014 for people who are disabled or 65 and older. But reimbursements declined in 2015 because of sequestration. And now Medicaid reimbursements rates starting to decrease as well.

Miller believes the shortage of physicians who are willing to make home visits is directly attributable to this inadequate payment for service.

“The big question is: Is there ever going to be a system where home healthcare providers can be reimbursed appropriately so that we can create a greater workforce of home care providers?”

She sure hopes so.

Photographer Misha Friedman says he tries to “look beyond the facts, searching for causes, and asking complex and difficult questions.” His work has been featured by many media organizations, including NPR, The New Yorker, Sports Illustrated, Spiegel and GQ.

Freelance writer Nadia Whitehead contributed to this report.

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The U.S. Supreme Court justices said Friday they would hear a group of cases brought by religious hospitals, schools, and charities that object to the system devised under Obamacare to spare them from paying for birth control coverage for their employees and students.

NPR’s Nina Totenberg reports:

“To accommodate religious groups that object to contraception, the Obama administration promulgated regulations that allow religious non-profits to opt out of birth control coverage by notifying the Department of Health and Human Services of their religious objection. That in turn triggers an independent system of birth control coverage for those employees or students who want it. A variety of religious non-profits contend that the opt-out notification itself burdens their religious faith. The Obama administration counters that the refusal to notify would amount to a religious believer’s veto of the rights of others who do not hold the same beliefs.”

The decision to hear yet another challenge to the Affordable Care Act — the fourth since 2010 — follows a 2014 decision in the Hobby Lobby case, which allowed “closely held” companies to opt out of the Affordable Care Act’s provisions for no-cost prescription contraception in most health insurance if they have religious objections.

Hobby Lobby is an arts and crafts chain owned by the Green family, who are evangelical Christians. The Supreme Court validated their objection to the contraception mandate saying it violated the Religious Freedom Restoration Act.

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Dr. Odontuya Davaasuren has one goal: to improve the way people die in Mongolia.

“My father died of lung cancer, my mother died, my mother-in-law died because of liver cancer,” she says. “Even though I was a doctor, I could do nothing.”

The feeling of helplessness, and the unnecessary pain her relatives suffered, is what Davaasuren has set out to fix. She has white hair because of it, says the family doctor and professor at the Mongolian National University of Medical Sciences in Ulaanbaatar. “It’s very hard work.”

Her efforts have earned her the title “the mother of palliative care in Mongolia.” And they’ve transformed the way people die.

In global rankings on quality of death released this fall by the Economist Intelligence Unit, Mongolia stood out. It’s number 28 on the list. “Some countries with lower income levels demonstrate the power of innovation and individual initiative,” the report noted, citing Mongolia for “rapid growth in hospice facilities and teaching programs.”

That’s no small feat, regardless of a country’s income level. Palliative care is a relatively new field. Funding tends to go toward combating infectious diseases, rather than towards easing the pain for those who have incurable illness. Hospitals might not want to consider offering hospice care, because it would simply increase the number of deaths that happen on their watch. And globally, doctors and law enforcement officers fear morphine, which happens to be one of the cheapest and most effective painkillers.

Most Mongolians die from noncommunicable illnesses like heart disease, cancer, and diabetes. The country is huge and sparsely populated, so most people die at home. About a third of the population lives under the poverty line. The monthly salary of a nurse is around $100. But the progress on end-of-life care that Mongolia has made contrast sharply to the situation in neighboring Russia, a country with some of the most restrictive drug regulations, and where Human Rights Watch says the government has barred journalists from reporting on suicide committed by cancer patients in severe pain.

In Mongolia, as in many other countries, there used to be two options for terminally ill people on their deathbeds: stay at home or go to the intensive care unit, or ICU. A bad death, Davaasuren says, is to die in the ICU, connected to machines, alone, watching the white hospital ceiling, and getting lab tests every few hours. “In the intensive care unit, patients are swaddled by machines and tubes. It’s a stupid death. It’s a really bad death,” she says.

American surgeon and writer Dr. Atul Gawande agrees. Even in the U.S., he writes in his best-seller Being Mortal, “You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. These days are spent in institutions — nursing homes and intensive-care units — where regimented, anonymous routines cut us off from all the things that matter to us in life.”

In the ICU, says Davaasuren, “even if all signs show that the patient will die,” all kinds of tests and treatments are given in the name of survival, even if it dims the quality of life. It used to be that the only alternative was to die at home, sometimes in pain. But a good death, says Davaasuren, is “being comfortable, being with loved people, listening to good words. Even an unconscious person listens, because hearing stops last.”

Davaasuren first learned about palliative care in Sweden in 2000.

Back then, she says, there wasn’t even terminology for palliative care in her country. She’s now the president of the Mongolian Palliative Care Society and has worked to change things.

After the conference in Sweden, she and her students visited patients with severe diagnoses and filmed their conversations. “During these visits I saw so much suffering, so many problems. Not just physical pain – psychological problems, financial problems, spiritual,” she says. A woman with two small children had such severe pain she asked to die. A man in his 30s committed suicide when he was left in unbearable pain after his allotted two-day supply of morphine was up. Families spent fortunes, she says, in search of alternative treatment and medication. “They went to Korea, went to China, looking for better treatment,” she says.

Davaasuren eventually spoke on national TV in the early 2000s about the lack of palliative care in Mongolia, saying that according to WHO recommendations Mongolia was in need of 150 palliative care beds. It had zero. “I had very strong words to the Ministry of Health,” she says.

“When I started to talk about it, many people in the Ministry of Health told me ‘What are you talking about? We have no money for living patients, why do you want to spend money for dying patients?” she says.

Bit by bit, she and her colleagues have managed to turn the tide. Davaasuren and her colleagues translated international publications on palliative care into Mongolian. A grant in 2004 from the Open Society Foundation helped them start courses for nurses and doctors. They worked to change prescription rules so that suffering patients could get cheap painkillers. She brought a hospice doctor from California and a hospice nurse from Virginia to train health workers on palliative care.

Now, poor families taking care of a terminally ill person can get about 36,000 tugrik [$18] each month from the government until the patient dies. “It’s very small but still supportive,” says Davaasuren.

“Before in Mongolia we had the wrong drug regulation,” she says. It used to be that only oncologists could prescribe morphine, and they could give a maximum of ten doses to a patient. Studies on cancer patients before 2000 found that they often died within a month after getting the painkillers – and the incorrect assumption was that the morphine killed them, says Davaasuren.

The country started importing oral morphine tablets in 2006. There is now one pharmacy in each of Mongolia’s 21 provinces with the right to distribute opioids. Before, there was only one. (Because of international regulations, the drugs have to be kept locked up and under security camera surveillance.) At least two people in each province – usually a family doctor and a nurse who are trained in palliative care – can prescribe opioids. “Now oncologists, family doctors have the right to prescribe opioids according to the patient’s needs, every seven days until death,” she says.

In 2000, writes Davaasuren, Mongolia as a whole only used two pounds of morphine a year. By 2004, it was 13 pounds. Last year, according to the Ministry of Health, the country imported a combined 48 pounds of opioid painkillers. A Mongolian company now produces morphine, codeine and pethidine and will this year start producing oxycodone.

There are about 60 beds designated for palliative care in the capital alone. Last month, the Ministry of Health signed off on plans to provide 596 palliative care beds across the country by 2017. The goal now, says Davaasuren, is to extend palliative care to non-cancer patients and to terminally ill children — and to redefine a good death as a success. “Hospitals don’t like to have palliative care patients because if patients die, it increases the death rate in their hospital,” she says. She’s working to get palliative care deaths registered outside of the hospital system.

Davaasuren continues to teach courses to medical students on topics like pain management and how to break bad news. Because sooner or later, she says, “each family will face this problem.”

“Mongolian people say we have one truth,” she adds. “If we are born on this earth, we will die one day.”

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