Difference between revisions of "Increase Access to Contraception"

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= Introductory Paragraph =
= Introductory Paragraph =


Family planning and preconception care for women who use opioids are important strategies to reduce the incidence of neonatal abstinence syndrome (NAS). <ref>https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm</ref> The CDC and the Office of Population Affairs of the U.S. Department of Health and Human Services recommend that health care providers support family planning services. This includes preconception services, pregnancy intention screening, and contraceptive counseling to prevent unintended pregnancy. It is recommended that access is increased to the full range of contraceptive methods, including long-acting reversible contraception, such as intrauterine devices and implants. <ref>Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63(No. RR-4)</ref>
An important strategy to reduce the incidence of fetal alcohol syndrome (FAS) and neonatal abstinence syndrome (NAS) is to increase family planning and preconception care for people who use substances. <ref>https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm</ref> The CDC and the Office of Population Affairs of the U.S. Department of Health and Human Services recommend that health care providers support family planning services. This includes preconception services, pregnancy intention screening, and contraceptive counseling to prevent unintended pregnancy. It is recommended that access is increased to the full range of contraceptive methods, including long-acting reversible contraception, such as intrauterine devices and implants. <ref>Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63(No. RR-4)</ref>


= Key Information =
= Key Information =


In the general population, 31–47% of pregnancies in the US are unintended. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/</ref> Approximately half of these end in termination of pregnancy. <ref>Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States 1994–2001. Perspect Sex Reprod Health. 2006;38:90.</ref> One study of 946 women who were using opioids who gave birth revealed that 86% reported that the pregnancy was unintended.<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/</ref> In another study in Eastern Tennessee on women who were using opioids who gave birth, it was found that their general knowledge of birth control was very low and that only 3% of them used a reliable birth control method. <ref>https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917</ref>  
In the general population, 31–47% of pregnancies in the US are unintended. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/</ref> Approximately half of these end in termination of pregnancy. <ref>Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States 1994–2001. Perspect Sex Reprod Health. 2006;38:90.</ref> One study of 946 pregnant people who were using opioids who gave birth revealed that 86% reported that the pregnancy was unintended. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/</ref> In another study in Eastern Tennessee on pregnant people who were using opioids, it was found that their general knowledge of birth control was very low and that only 3% of them used a reliable birth control method. <ref>https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917</ref> While there is often disagreement on what type of sex education is appropriate, communities should make it a priority to improve understanding of birth control as a way to avoid unintended pregnancies. Unintended pregnancies result from contraceptive failure, incorrect or inconsistent use of a method, or lack of use of any form of contraception. <ref>Jones RK, Darroch JE, Henshaw SK. Contraceptive use among U.S. women having abortions in 2000–2001. Perspect Sex Reprod Health. 2002;34:294–303.</ref> <ref>Moreau C, Trussell J, Rodrigues G, Bajoo N, Bouyer J. Contraceptive failure rate in France: results from a population based survey. Hum Reprod Update. 2007;22:2422–7.</ref> Interventions to increase adherence to pills and condoms, such as enhanced counseling, have not consistently improved contraceptive use patterns, continuation rates (ongoing use of the method after 12 months), or unintended pregnancies. <ref>Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368:1810–27.</ref> One study found that people using user-depended methods (pills, patches, and rings) were 20 times more likely to have an unplanned pregnancy than those using an intrauterine device (IUD) or implant. <ref>Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–2007.</ref>


While there is often disagreement on what type of sex education is appropriate, communities should make it a priority to improve understanding of birth control as a way to avoid unintended pregnancies. Unintended pregnancies result from contraceptive failure, incorrect or inconsistent use of a method, or lack of use of any form of contraception. <ref>Jones RK, Darroch JE, Henshaw SK. Contraceptive use among U.S. women having abortions in 2000–2001. Perspect Sex Reprod Health. 2002;34:294–303.</ref> <ref>Moreau C, Trussell J, Rodrigues G, Bajoo N, Bouyer J. Contraceptive failure rate in France: results from a population based survey. Hum Reprod Update. 2007;22:2422–7.</ref> Interventions to increase adherence to pills and condoms, such as enhanced counseling, have not consistently improved contraceptive use patterns, continuation rates (ongoing use of the method after 12 months), or unintended pregnancies. <ref>Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368:1810–27.</ref> One study found that women using user-depended methods (pills, patches, and rings) were 20 times more likely to have an unplanned pregnancy than women using an intrauterine device (IUD) or implant.<ref>Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–2007.</ref>
IUDs and the implants are collectively known as long-acting reversible contraception (LARC) methods. These are the most effective and cost-effective reversible methods available. They have an inherent ability to prevent pregnancy, but their effectiveness also arises from the fact that they are set and forget methods that do not require daily compliance, unlike condoms or the oral contraceptive pill. These are attributes that are rated highly when considering contraceptive options. <ref>Madden T, Secura GM, Nease RF, Politi MC, Peipert JF. The role of contraceptive attributes in women’s contraceptive decision making. Am J Obstet Gynecol. 2015;213(1):e41–6.</ref> Therefore, increased use of LARCs should be promoted. One way may be via the integration of contraceptive services into drug health clinics. In this way, people may be enabled to more easily address their various needs in an environment that is both more familiar and less threatening. Similarly, integrated services may be more successful if they can provide low-threshold service access, i.e., services with few or no barriers to access. <ref>Islam MM, Topp L, Conigrave KM, Day CA. Defining a service for people who use drugs as ‘low-threshold’: what should be the criteria? Int J Drug Policy. 2013;24(3):220–2.</ref> <ref>Islam MM, Topp L, Conigrave KM, Day CA. Opioid substitution therapy clients’ preferences for targeted versus general primary health-care outlets. Drug Alcohol Rev. 2013;32:211–3. </ref> These forms of birth control last for years once inserted and prevent pregnancy for more than 99 percent of users. Since 2007, there has been a sharp rise in LARCs, which helps explain why they are a big part of the story behind America's decreasing rate of unintended pregnancies. <ref>https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud</ref>  


IUDs and the implants are collectively known as long-acting reversible contraception (LARC) methods. These are the most effective and cost-effective reversible methods available. They have an inherent ability to prevent pregnancy, but their effectiveness also arises from the fact that they are set and forget methods that do not require daily compliance, unlike condoms or the oral contraceptive pill. These are attributes that women themselves rate highly when considering their contraceptive options.<ref>Madden T, Secura GM, Nease RF, Politi MC, Peipert JF. The role of contraceptive attributes in women’s contraceptive decision making. Am J Obstet Gynecol. 2015;213(1):e41–6.</ref> Therefore, using LARCs should be promoted. One way may be via the integration of contraceptive services into drug health clinics. In this way, women may be enabled to more easily address their various needs in an environment that is both more familiar and less threatening. Similarly, integrated services may be more successful if they can provide low-threshold service access, ie, services with few or no barriers to access. <ref>Islam MM, Topp L, Conigrave KM, Day CA. Defining a service for people who use drugs as ‘low-threshold’: what should be the criteria? Int J Drug Policy. 2013;24(3):220–2.</ref> <ref>Islam MM, Topp L, Conigrave KM, Day CA. Opioid substitution therapy clients’ preferences for targeted versus general primary health-care outlets. Drug Alcohol Rev. 2013;32:211–3. </ref> An analysis of a publicly funded family planning program calculated that LARC methods save US$7 in costs from unintended pregnancy for every US$1 spent. Thus, improving access to LARC methods is likely to be cost-effective. <ref>Foster D, Rostovtseva D, Brindis C, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific methods of contraception in a publicly funded program. Am J Public Health. 2009;99:446–51.</ref>
'''Barriers.'''
 
*Perception. Approximately 1 in 7 ob/gyns continue to believe pelvic inflammatory disease is a significant risk of IUD use, despite substantial research to the contrary. <ref>Luchowski, A.T., et al. (2014). Obstetrician-Gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women, adolescents and other patient populations. Contraception 89.</ref>
== Offer Contraception at Pain Management/Addiction/Methadone/Suboxone clinics ==
*Cost. One of the biggest obstacles to LARC use, historically, has been price. Planned Parenthood has estimated that IUDs can cost between $500 and $900 out of pocket. Insurance plans tend to charge patients more for IUDs than for birth control pills, because the devices have such high upfront costs. <ref>https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud</ref>
 
*Copayments. Patient contraceptive selection is sensitive to copayment. One analysis confirmed that employer-based plans display significant variation in copayments by contraceptive method, with LARC methods being the most expensive in terms of upfront costs to patients. <ref>Dusetzina, S.B., Dalton, V.K., Chernew, M.E., Pace, L.E., Bowden, G., and Fendrick, A.M. Cost of contraceptive methods to privately insured women in the United States. Women's Health Issues. 2013; 23: e69–71</ref>
The feasibility of delivery of family planning services at addiction treatment clinics is being actively explored, as seen from a study completed in West North Carolina. <ref>https://sys.mahec.net/media/onlinejournal/Contraceptive%20Choices.pdf</ref>
*Insurance complexities. The American College of Obstetricians and Gynecologists (ACOG) supports placement of LARC devices during the immediate postpartum period to improve the use of LARC during postpartum. However, bundled payments for delivery create a relative financial disincentive to place LARC devices at the time of delivery. <ref>https://pediatrics.aappublications.org/content/139/3/e20164070</ref>  
 
*State variability. State Medicaid programs play a critical role in ensuring access to highly effective contraception at the time when it is desired, including the time of delivery. However, recent research suggests that states are variable in aligning financial incentives to ensure access to LARC methods if elected at the time of delivery. <ref>Pace, L.E., Dusetzina, S.B., Fendrick, A.M., Keating, N.L., and Dalton, V.K. The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance. Medical Care. 2013; 51: 959–963</ref>
Offer contraception planning in non-traditional venues, such as a pediatric clinic within a drug treatment facility. <ref>https://doi.org/10.1080/15332985.2011.575723</ref> A barrier is staff education and comfort discussing the issue. Education and availability of appropriate staff would be paramount.
 
Contraceptive counseling and access to contraceptive services should be a routine part of substance use disorder treatment among women of reproductive age to mitigate the risk of unplanned pregnancy.<ref>https://www.regulations.gov/document?D=SAMHSA-2016-0002-0001</ref>


= Relevant Research =
= Relevant Research =


== Research on Birth Control Options ==
*The Family Planning Initiative was a four-year project that delivered contraceptive services in a pediatric clinic within a drug treatment facility. They found that staff education levels and discomfort discussing the issue were barriers and recommend education and availability of appropriate staff.  <ref>https://doi.org/10.1080/15332985.2011.575723</ref>


See this article on [https://www.bedsider.org/features/224-gold-standard-birth-control-the-iud-and-the-implant preferences and effectiveness of different birth control options]
*This study completed in Western North Carolina documents the feasibility of delivery of family planning services at addiction treatment clinics.  <ref>https://sys.mahec.net/media/onlinejournal/Contraceptive%20Choices.pdf</ref>


*This article provides a summary of an initiative by researchers at the Contraceptive CHOICE Project at Washington University in St. Louis. Women in the St. Louis region were offered access to any kind of birth control they wanted for free. The article documents the methods the participants chose and how well their choices worked for them. <ref>https://www.bedsider.org/features/224-gold-standard-birth-control-the-iud-and-the-implant</ref>


*A cost-benefit analysis of a publicly funded family planning program calculated that LARC methods save US$7 in costs from unintended pregnancy for every US$1 spent. Thus, improving access to LARC methods is likely to be cost-effective. <ref>Foster D, Rostovtseva D, Brindis C, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific methods of contraception in a publicly funded program. Am J Public Health. 2009;99:446–51.</ref>


== LARCs ==
= Impactful Federal, State, and Local Policies =


Increasing access to Long-Acting Reversible Contraceptives (LARCs) could be a key part of a strategy. Since 2007, researchers have seen a sharp rise in LARCs, such as intrauterine devices and implants. These forms of birth control last for years once inserted and prevent pregnancy for more than 99 percent of users. That helps explain why they're a big part of the story behind America's plummeting unintended pregnancy rate. <ref>https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud</ref> One of the biggest obstacles to LARC use, historically, has been price. Planned Parenthood has estimated that IUDs can cost between $500 and $900 out of pocket. Insurance plans tended to charge patients more for IUDs than for birth control pills, just because the devices have such high upfront costs. <ref>https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud</ref> [http://www.latimes.com/health/la-he-0528-birth-control-20160515-snap-story.html This article] makes some interesting points and has information on the relative effectiveness of different types of contraceptives.
*The Medicaid program has always required that family planning services be fully covered for patients without cost sharing. <ref>National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions.</ref>  


== Hormone-releasing Implants ==
*The Patient Protection and Affordable Care Act (ACA) similarly required new private health plans to provide no-cost coverage for all FDA-approved contraceptives. <ref>https://www.patientassistance.bayer.us/</ref>


[https://www.nexplanon.com NEXPLANON] is a hormone-releasing birth control implant for use by women to prevent pregnancy for up to 3 years.
*SAMHSA maintains that contraceptive counseling and access to contraceptive services should be a routine part of substance use disorder treatment among women of reproductive age to mitigate the risk of unplanned pregnancy. <ref>https://www.regulations.gov/document?D=SAMHSA-2016-0002-0001</ref>


== Non-Hormone IUDs ==
*Virginia law allows women a full year of birth control covered by insurance vs. the previous 3-month supply. <ref>https://lis.virginia.gov/cgi-bin/legp604.exe?212+sum+SB1227</ref>


[http://www.paragard.com Paragard] is an IUD that can prevent pregnancy for up to 10 years. Paragard is a hormone-free IUD. It may be 100% covered by insurance. See [http://Paragardbvsp.com Paragardbvsp.com] to learn if benefits cover Paraguard.
= Available Tools and Resources =


== Overcoming Cost Barriers to Access ==
*This brief news article provides information on the relative effectiveness of different types of contraceptives and the complexity of choices involved. <ref>http://www.latimes.com/health/la-he-0528-birth-control-20160515-snap-story.html</ref>


Healthcare providers or clinics can join a Group Purchasing Organization (GPO) to get lower costs on birth control. Afaxys is a pharma company that produces birth control pills, but they also have a Group Purchasing Organization that provides discount pricing on Bayer IUDs.
*"A Step Ahead" in East Tennessee provides transportation to an appointment for a free LARC and a free wellness visit that includes a pregnancy test and an STI test. Those over 21 with a medical provider referral may also receive a free PAP test.​ <ref>http://www.astepaheadeasttn.org/faq.html</ref>


*NEXPLANON is a hormone-releasing birth control implant which prevents pregnancy for up to 3 years. <ref>https://www.nexplanon.com</ref>


== Other Barriers to Access ==
*Paragard is an IUD that can prevent pregnancy for up to 10 years. Paragard is a hormone-free IUD and may be 100% covered by insurance.  <ref>http://www.paragard.com</ref>


Approximately 1 in 7 ob/gyns believe pelvic inflammatory disease is a significant risk of IUD use, despite substantial research to the contrary.<ref>Luchowski, A.T., et al. (2014). Obstetrician-Gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women, adolescents and other patient populations. Contraception 89.</ref>
*Healthcare providers or clinics can join a Group Purchasing Organization (GPO) to get lower costs on birth control. Afaxys is a pharmaceutical company that produces birth control pills. It has a GPO that provides discount pricing on Bayer IUDs.


== Contraceptive Counseling ==
*Project Prevention uses donation funding to provide a $300 payment to support getting on long-term birth control. <ref>https://projectprevention.org/</ref>
 
EmpowerHealth USA provides a telehealth option for contraception counseling.<ref>https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917</ref>
 
== Potential Barriers ==
 
"For example, the ACOG supports placement of LARC devices during the immediate postpartum period to improve the use of LARC among postpartum women; however, bundled payments for delivery create a relative financial disincentive to place LARC devices at the time of delivery. <ref>https://pediatrics.aappublications.org/content/139/3/e20164070</ref> State Medicaid programs play a critical role in ensuring access to highly effective contraception at the time when it is desired, including the time of delivery. However, recent research suggests that states are variable in aligning financial incentives to ensure access to LARC methods if elected at the time of delivery." <ref>Pace, L.E., Dusetzina, S.B., Fendrick, A.M., Keating, N.L., and Dalton, V.K. The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance. Medical Care. 2013; 51: 959–963</ref> Patient contraceptive selection is sensitive to copayment. A 2010 analysis confirmed that employer-based plans display significant variation in copayments by contraceptive method, with LARC methods being the most expensive in terms of upfront costs to patients. <ref>Dusetzina, S.B., Dalton, V.K., Chernew, M.E., Pace, L.E., Bowden, G., and Fendrick, A.M. Cost of contraceptive methods to privately insured women in  the United States. Women's Health Issues. 2013; 23: e69–71</ref> The Medicaid program has always required that family planning services be fully covered for patients without cost sharing.<ref>National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions. Accessed August 24, 2015. </ref> The Patient Protection and Affordable Care Act (ACA) similarly required new private health plans to provide no-cost coverage for all FDA-approved contraceptives.<ref>https://www.patientassistance.bayer.us/</ref>
 
= Impactful Federal, State, and Local Policies =
 
Virginia law allows women a full year of birth control covered by insurance vs. the previous 3-month supply. <ref>https://lis.virginia.gov/cgi-bin/legp604.exe?212+sum+SB1227</ref>
 
= Available Tools and Resources =
 
*Project Prevention relies on donations and pays women $300 to get on long-term birth control<ref>https://projectprevention.org/</ref>
 
*Tennessee Department of Health officials are sharing the project’s success. Some 41 local jails and methadone clinics now work with county health officials to make available free IUDs. The project is paid for by federal funds for incarcerated women who don't have private insurance or have lost TennCare, which automatically ends during incarceration. Officials stress that the choice to obtain long-acting and reversible contraceptives is up to each incarcerated woman.<ref>https://www.tennessean.com/story/news/2017/02/04/iuds-inmates-seen-tool-combat-opioid-crisis/97056396/</ref>
 
*The Access and Resources in Contraceptive Health (ARCH) Patient Assistance Program provides Bayer IUDs (Kyleena, Mirena, and Skyla) at no cost to women in the United States who do not have either private health insurance or Medicaid coverage for Bayer IUDs and who meet all other program eligibility requirements. Please note that while Bayer provides Bayer IUDs at no cost to patients, patients may incur other costs such as insertion and removal costs. Please speak with your insurance company or your healthcare provider for more information.
 
* "A Step Ahead" In East Tennessee - With an appointment for free birth control (LARC), will provide a free "Well Woman's" visit, including a pregnancy test and STI test. If you are over 21 and your medical provider deems it medically necessary, you may also receive a free PAP test.​ They also provide transportation. <ref>http://www.astepaheadeasttn.org/faq.html</ref>


= Promising Practices =
= Promising Practices =


== NAS Primary Prevention Initiative ==
*'''emPOWERhealth USA''' has a program that provides tele-health with a focus on women who are using opioids. They provide coaching on birth control to help more people get LARCs or make other informed decisions on birth control. <ref>https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917</ref>  
 
[https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjCts7gtNDzAhWsl3IEHY0_Bx8QFnoECAkQAQ&url=https://www.tn.gov/content/dam/tn/health/documents/Bright_Spot_East_Region_NAS_Reduction_Effort_10-6-14_mbb_10-10-14.docx&usg=AOvVaw38qzEf-QI-U4gTE-ix_-Wj East Tennessee Primary Prevention Initiative] - Tennessee Department of Health
Contact: Erica Wilson, MPH, Community Services Director, [mailto:erica.wilson@tn.gov erica.wilson@tn.gov]
 
'''Overview of program'''
 
*Partnership with local jails
*Health education sessions
**focus on NAS prevention
**information on effective contraceptives and LARCs 
*Partnerships with jails to refer inmates to local health department for family planning
*Among 442 referrals (2014-15), 94% received a contraceptive method, 84% chose a voluntary LARC
 
''Resources'':
 
*PowerPoint presentation - to educate community partners 
*Pamphlet - to educate community partners 
*Presentation - conducted to inmates on NAS and how it can be prevented 
 
== emPOWERhealthUSA ==
 
emPOWERhealthUSA has a program that provides telehealth coaching on birth control (among other things) to help more women get LARCs or make other informed decisions on birth control, with a focus on women who are using opioids. <ref>https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917</ref>  


== Access and Resources in Contraceptive Health (ARCH) Patient Assistance Program ==
*'''The Tennessee Department of Health''' has a NAS Primary Prevention Initiative that is working with over 40 local jails and Methadone clinics to make make family planning and free IUDs available. The project is paid for by federal funds for incarcerated women who don't have private insurance or have lost TennCare, which automatically ends during incarceration. 94% of them received a contraceptive method, and 84% chose a voluntary LARC. Officials stress that the choice to obtain LARCs is up to each incarcerated person. <ref>https://www.tennessean.com/story/news/2017/02/04/iuds-inmates-seen-tool-combat-opioid-crisis/97056396/</ref> <ref>https://www.tn.gov/content/dam/tn/health/documents/Bright_Spot_East_Region_NAS_Reduction_Effort_10-6-14_mbb_10-10-14.docx</ref>


This patient assistance program provides Bayer IUDs (intrauterine devices), Kyleena, Mirena, and Skyla, at no cost to eligible women. <ref>https://www.patientassistance.bayer.us/</ref> Eligible women include those who do not have either private health insurance or Medicaid coverage for Bayer IUDs and who meet all other program eligibility requirements. Kyleena and Mirena can help prevent pregnancy for up to 5 years and Skyla up to 3 years. <ref>https://www.patientassistance.bayer.us/</ref>
*'''Access and Resources in Contraceptive Health (ARCH).''' This patient assistance program provides Bayer IUDs (the 3-year Skyla IUD and the 5-year Kyleena and Mirena IUDs), at no cost. Eligibility includes those who do not have either private health insurance or Medicaid coverage. Although the IUDs are free, patients may incur other costs such as insertion and removal costs. <ref>https://www.patientassistance.bayer.us/</ref>


= Sources =
= Sources =

Latest revision as of 11:24, 30 November 2024

Introductory Paragraph

An important strategy to reduce the incidence of fetal alcohol syndrome (FAS) and neonatal abstinence syndrome (NAS) is to increase family planning and preconception care for people who use substances. [1] The CDC and the Office of Population Affairs of the U.S. Department of Health and Human Services recommend that health care providers support family planning services. This includes preconception services, pregnancy intention screening, and contraceptive counseling to prevent unintended pregnancy. It is recommended that access is increased to the full range of contraceptive methods, including long-acting reversible contraception, such as intrauterine devices and implants. [2]

Key Information

In the general population, 31–47% of pregnancies in the US are unintended. [3] Approximately half of these end in termination of pregnancy. [4] One study of 946 pregnant people who were using opioids who gave birth revealed that 86% reported that the pregnancy was unintended. [5] In another study in Eastern Tennessee on pregnant people who were using opioids, it was found that their general knowledge of birth control was very low and that only 3% of them used a reliable birth control method. [6] While there is often disagreement on what type of sex education is appropriate, communities should make it a priority to improve understanding of birth control as a way to avoid unintended pregnancies. Unintended pregnancies result from contraceptive failure, incorrect or inconsistent use of a method, or lack of use of any form of contraception. [7] [8] Interventions to increase adherence to pills and condoms, such as enhanced counseling, have not consistently improved contraceptive use patterns, continuation rates (ongoing use of the method after 12 months), or unintended pregnancies. [9] One study found that people using user-depended methods (pills, patches, and rings) were 20 times more likely to have an unplanned pregnancy than those using an intrauterine device (IUD) or implant. [10]

IUDs and the implants are collectively known as long-acting reversible contraception (LARC) methods. These are the most effective and cost-effective reversible methods available. They have an inherent ability to prevent pregnancy, but their effectiveness also arises from the fact that they are set and forget methods that do not require daily compliance, unlike condoms or the oral contraceptive pill. These are attributes that are rated highly when considering contraceptive options. [11] Therefore, increased use of LARCs should be promoted. One way may be via the integration of contraceptive services into drug health clinics. In this way, people may be enabled to more easily address their various needs in an environment that is both more familiar and less threatening. Similarly, integrated services may be more successful if they can provide low-threshold service access, i.e., services with few or no barriers to access. [12] [13] These forms of birth control last for years once inserted and prevent pregnancy for more than 99 percent of users. Since 2007, there has been a sharp rise in LARCs, which helps explain why they are a big part of the story behind America's decreasing rate of unintended pregnancies. [14]

Barriers.

  • Perception. Approximately 1 in 7 ob/gyns continue to believe pelvic inflammatory disease is a significant risk of IUD use, despite substantial research to the contrary. [15]
  • Cost. One of the biggest obstacles to LARC use, historically, has been price. Planned Parenthood has estimated that IUDs can cost between $500 and $900 out of pocket. Insurance plans tend to charge patients more for IUDs than for birth control pills, because the devices have such high upfront costs. [16]
  • Copayments. Patient contraceptive selection is sensitive to copayment. One analysis confirmed that employer-based plans display significant variation in copayments by contraceptive method, with LARC methods being the most expensive in terms of upfront costs to patients. [17]
  • Insurance complexities. The American College of Obstetricians and Gynecologists (ACOG) supports placement of LARC devices during the immediate postpartum period to improve the use of LARC during postpartum. However, bundled payments for delivery create a relative financial disincentive to place LARC devices at the time of delivery. [18]
  • State variability. State Medicaid programs play a critical role in ensuring access to highly effective contraception at the time when it is desired, including the time of delivery. However, recent research suggests that states are variable in aligning financial incentives to ensure access to LARC methods if elected at the time of delivery. [19]

Relevant Research

  • The Family Planning Initiative was a four-year project that delivered contraceptive services in a pediatric clinic within a drug treatment facility. They found that staff education levels and discomfort discussing the issue were barriers and recommend education and availability of appropriate staff. [20]
  • This study completed in Western North Carolina documents the feasibility of delivery of family planning services at addiction treatment clinics. [21]
  • This article provides a summary of an initiative by researchers at the Contraceptive CHOICE Project at Washington University in St. Louis. Women in the St. Louis region were offered access to any kind of birth control they wanted for free. The article documents the methods the participants chose and how well their choices worked for them. [22]
  • A cost-benefit analysis of a publicly funded family planning program calculated that LARC methods save US$7 in costs from unintended pregnancy for every US$1 spent. Thus, improving access to LARC methods is likely to be cost-effective. [23]

Impactful Federal, State, and Local Policies

  • The Medicaid program has always required that family planning services be fully covered for patients without cost sharing. [24]
  • The Patient Protection and Affordable Care Act (ACA) similarly required new private health plans to provide no-cost coverage for all FDA-approved contraceptives. [25]
  • SAMHSA maintains that contraceptive counseling and access to contraceptive services should be a routine part of substance use disorder treatment among women of reproductive age to mitigate the risk of unplanned pregnancy. [26]
  • Virginia law allows women a full year of birth control covered by insurance vs. the previous 3-month supply. [27]

Available Tools and Resources

  • This brief news article provides information on the relative effectiveness of different types of contraceptives and the complexity of choices involved. [28]
  • "A Step Ahead" in East Tennessee provides transportation to an appointment for a free LARC and a free wellness visit that includes a pregnancy test and an STI test. Those over 21 with a medical provider referral may also receive a free PAP test.​ [29]
  • NEXPLANON is a hormone-releasing birth control implant which prevents pregnancy for up to 3 years. [30]
  • Paragard is an IUD that can prevent pregnancy for up to 10 years. Paragard is a hormone-free IUD and may be 100% covered by insurance. [31]
  • Healthcare providers or clinics can join a Group Purchasing Organization (GPO) to get lower costs on birth control. Afaxys is a pharmaceutical company that produces birth control pills. It has a GPO that provides discount pricing on Bayer IUDs.
  • Project Prevention uses donation funding to provide a $300 payment to support getting on long-term birth control. [32]

Promising Practices

  • emPOWERhealth USA has a program that provides tele-health with a focus on women who are using opioids. They provide coaching on birth control to help more people get LARCs or make other informed decisions on birth control. [33]
  • The Tennessee Department of Health has a NAS Primary Prevention Initiative that is working with over 40 local jails and Methadone clinics to make make family planning and free IUDs available. The project is paid for by federal funds for incarcerated women who don't have private insurance or have lost TennCare, which automatically ends during incarceration. 94% of them received a contraceptive method, and 84% chose a voluntary LARC. Officials stress that the choice to obtain LARCs is up to each incarcerated person. [34] [35]
  • Access and Resources in Contraceptive Health (ARCH). This patient assistance program provides Bayer IUDs (the 3-year Skyla IUD and the 5-year Kyleena and Mirena IUDs), at no cost. Eligibility includes those who do not have either private health insurance or Medicaid coverage. Although the IUDs are free, patients may incur other costs such as insertion and removal costs. [36]

Sources

 

  1. ↑ https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm
  2. ↑ Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63(No. RR-4)
  3. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/
  4. ↑ Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States 1994–2001. Perspect Sex Reprod Health. 2006;38:90.
  5. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/
  6. ↑ https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917
  7. ↑ Jones RK, Darroch JE, Henshaw SK. Contraceptive use among U.S. women having abortions in 2000–2001. Perspect Sex Reprod Health. 2002;34:294–303.
  8. ↑ Moreau C, Trussell J, Rodrigues G, Bajoo N, Bouyer J. Contraceptive failure rate in France: results from a population based survey. Hum Reprod Update. 2007;22:2422–7.
  9. ↑ Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368:1810–27.
  10. ↑ Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–2007.
  11. ↑ Madden T, Secura GM, Nease RF, Politi MC, Peipert JF. The role of contraceptive attributes in women’s contraceptive decision making. Am J Obstet Gynecol. 2015;213(1):e41–6.
  12. ↑ Islam MM, Topp L, Conigrave KM, Day CA. Defining a service for people who use drugs as ‘low-threshold’: what should be the criteria? Int J Drug Policy. 2013;24(3):220–2.
  13. ↑ Islam MM, Topp L, Conigrave KM, Day CA. Opioid substitution therapy clients’ preferences for targeted versus general primary health-care outlets. Drug Alcohol Rev. 2013;32:211–3.
  14. ↑ https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud
  15. ↑ Luchowski, A.T., et al. (2014). Obstetrician-Gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women, adolescents and other patient populations. Contraception 89.
  16. ↑ https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud
  17. ↑ Dusetzina, S.B., Dalton, V.K., Chernew, M.E., Pace, L.E., Bowden, G., and Fendrick, A.M. Cost of contraceptive methods to privately insured women in the United States. Women's Health Issues. 2013; 23: e69–71
  18. ↑ https://pediatrics.aappublications.org/content/139/3/e20164070
  19. ↑ Pace, L.E., Dusetzina, S.B., Fendrick, A.M., Keating, N.L., and Dalton, V.K. The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance. Medical Care. 2013; 51: 959–963
  20. ↑ https://doi.org/10.1080/15332985.2011.575723
  21. ↑ https://sys.mahec.net/media/onlinejournal/Contraceptive%20Choices.pdf
  22. ↑ https://www.bedsider.org/features/224-gold-standard-birth-control-the-iud-and-the-implant
  23. ↑ Foster D, Rostovtseva D, Brindis C, Biggs MA, Hulett D, Darney PD. Cost savings from the provision of specific methods of contraception in a publicly funded program. Am J Public Health. 2009;99:446–51.
  24. ↑ National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions.
  25. ↑ https://www.patientassistance.bayer.us/
  26. ↑ https://www.regulations.gov/document?D=SAMHSA-2016-0002-0001
  27. ↑ https://lis.virginia.gov/cgi-bin/legp604.exe?212+sum+SB1227
  28. ↑ http://www.latimes.com/health/la-he-0528-birth-control-20160515-snap-story.html
  29. ↑ http://www.astepaheadeasttn.org/faq.html
  30. ↑ https://www.nexplanon.com
  31. ↑ http://www.paragard.com
  32. ↑ https://projectprevention.org/
  33. ↑ https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917
  34. ↑ https://www.tennessean.com/story/news/2017/02/04/iuds-inmates-seen-tool-combat-opioid-crisis/97056396/
  35. ↑ https://www.tn.gov/content/dam/tn/health/documents/Bright_Spot_East_Region_NAS_Reduction_Effort_10-6-14_mbb_10-10-14.docx
  36. ↑ https://www.patientassistance.bayer.us/
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