Increase Access to Contraception

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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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