Increase Access to Contraception

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Return to  Opioid Top-Level Strategy Map or ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use

Intro paragraph

Background

Family planning and preconception care for women who use opioids is considered an important strategy to reduce the incidence of NAS. [1]  "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, which include preconception services, pregnancy intention screening, and contraceptive counseling to prevent unintended pregnancy by increasing access to the full range of contraceptive methods, including long-acting reversible contraception (e.g., intrauterine devices and implants)."[2]
Current Status

  • 31% to 47% of US pregnancies are unintended, research suggests that, for women with opioid use disorder, the proportion of unintended pregnancies was higher than 85%.[3]
  • The statistics of a study in Eastern Tennessee were alarming:
    • Half of the 320,000 women in Medicaid in Tennessee received an opioid prescription in 2016[4]
    • Only 3% of them use a reliable birth control method[5]
    • Their general knowledge of birth control is very low[6]

Improving Education about Contraception

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.
 

Prevention through Contraception

Long-Acting Reversible Contraception (LARC)

One-in-two pregnancies in the US are unintended, and approximately half of these end in termination of pregnancy.[7] Unintended pregnancies result from contraceptive failure, incorrect or inconsistent use of a method, or lack of use of any form of contraception.[8][9]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.[10] A US prospective 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.[11]


The IUDs and the implants are collectively known as LARC methods, and 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 of the oral contraceptive pill. These are attributes that women themselves rate highly when considering their contraceptive options.[12] 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.[13][14]

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.[15]

Incentives for LARC use

Project Prevention relies on donations and pays women $300 to get on long term birth control[16]
 

Organizations offering Free or Reduced LARC

The number of babies born with neonatal abstinence syndrome have dropped nearly 90 percent in one year in counties that have the program.
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.[17]

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.[18]

"A Step Ahead" In East Tennessee - With any appointment for free birth control (LARC), we 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.[19]

Offer Contraception at Pain Management/Addiction/Methadone/Suboxone clinics

The feasibility of delivery of family planning services at addiction treatment clinics is being actively explored - Study completed in West North Carolina[20]

Offer contraception planning in non-traditional venues, such as pediatric clinic within a drug treatment facility[21] 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.[22]

Virginia law allows women a full year of birth control covered by insurance vs. the previous 3 month supply

Research on Birth Control Options

See this article on preferences and effectiveness of different birth control options. 

 

LARCs

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. [23] 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.[24]  This article makes some interesting points and has information on the relative effectiveness of different types of contraceptives.
 

 

Hormone-releasing Implants

NEXPLANON is a hormone-releasing birth control implant for use by women to prevent pregnancy for up to 3 years.
 

Non-Hormone IUDs

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 Paragardbvsp.com to learn if benefits cover Paraguard. .

Overcoming Cost Barriers to Access

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.
 

 

Other Barriers to Access

Approximately 1 in 7 ob/gyns believe pelvic inflammatory disease is a significant risk of IUD use, despite substantial research to the contrary.[25]

 

Preconception Services


 

Pregnancy Intention Screening


 

Contraceptive Counseling

EmpowerHealth USA provides a telehealth option for contraception counseling.[26]

 

Statistics

  • A study of 946 women who were using opioids who gave birth revealed that 86% reported that the pregnacy was unintended.[27]

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.[28]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."[29]


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.[30] The Medicaid program has always required that family planning services be fully covered for patients without cost sharing.[31] The Patient Protection and Affordable Care Act (ACA) similarly required new private health plans to provide no-cost coverage for all FDA-approved contraceptives.[32]
 

Promising Programs

NAS Primary Prevention Initiative
East Tennessee Primary Prevention Initiative - Tennessee Department of Health
Contact: Erica Wilson, MPH, Community Services Director,  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 [contacted for resource]
  • Pamphlet - to educate community partners [contacted for resource]
  • Presentation - conducted to inmates on NAS and how it can be prevented [contacted for resource]

 

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.
 

Access and Resources in Contraceptive Health (ARCH) Patient Assistance Program

This patient assistance program provides Bayer IUDs (intrauterine devices), Kyleena, Mirena and Skyla, at no cost to eligible women.[33] 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.[34]

 

Tools & Resources

TR - Improve Access to Contraception

Scorecard Building

Potential Objective Details
Potential Measures and Data Sources
Potential Actions and Partners

Resources to Investigate

More RTI on Access to Contraception

PAGE MANAGER: [insert name here]
SUBJECT MATTER EXPERT: [fill out table below]

Reviewer Date Comments
     

 

Sources

 

 

  1. [3]
  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. [4]
  4. [5]
  5. [6]
  6. [7]
  7. [8]
  8. [9]
  9. 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.
  10. [10]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/ 
  11.  





















[11]

  •  









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

  • 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
  • National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions. Accessed August 24, 2015.
  •  








[12]

  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.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm
  4. ↑ http://www.empowerhealthusa.com/our-work.html
  5. ↑ http://www.empowerhealthusa.com/our-work.html
  6. ↑ http://www.empowerhealthusa.com/our-work.html
  7. ↑ Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States 1994–2001. Perspect Sex Reprod Health. 2006;38:90.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368:1810–27.
  11. ↑ Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–2007.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ https://www.heraldcourier.com/news/addicted_at_birth/project-prevention-program-aims-to-stop-nas-by-birth-control/article_3ebf4d37-5c7f-57b5-b297-47b1958127a5.html
  17. ↑ https://www.tennessean.com/story/news/2017/02/04/iuds-inmates-seen-tool-combat-opioid-crisis/97056396/
  18. ↑ http://www.archpatientassistance.com/
  19. ↑ http://www.astepaheadeasttn.org/faq.html
  20. ↑ https://sys.mahec.net/media/onlinejournal/Contraceptive Choices.pdf
  21. ↑ https://doi.org/10.1080/15332985.2011.575723
  22. ↑ https://www.regulations.gov/document?D=SAMHSA-2016-0002-0001
  23. ↑ https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud
  24. ↑ https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud
  25. ↑ 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.
  26. ↑ http://www.empowerhealthusa.com/our-work.html
  27. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052960/
  28. ↑ https://pediatrics.aappublications.org/content/139/3/e20164070
  29. ↑ 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
  30. ↑ 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
  31. ↑ National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions. Accessed August 24, 2015.
  32. ↑ https://www.patientassistance.bayer.us/
  33. ↑ https://www.patientassistance.bayer.us/
  34. ↑ https://www.patientassistance.bayer.us/
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