Increase Access to Contraception

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Introductory Paragraph

Family planning and preconception care for women who use opioids are important strategies to reduce the incidence of neonatal abstinence syndrome (NAS). [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 women who were using opioids who gave birth revealed that 86% reported that the pregnancy was unintended.[5] 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. [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 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.[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 women themselves rate highly when considering their contraceptive options.[11] 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. [12] [13] 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. [14]

Increasing access to 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. [15]

Barriers. 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. [16]

  • Approximately 1 in 7 ob/gyns believe pelvic inflammatory disease is a significant risk of IUD use, despite substantial research to the contrary.[17]

"For example, the the American College of Obstetricians and Gynecologists (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. [18] 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] 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. [20]

Relevant Research

  • 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. [21]
  • This article provides a summary of a groundbreaking 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]

Impactful Federal, State, and Local Policies

  • The Medicaid program has always required that family planning services be fully covered for patients without cost sharing.[23]
  • The Patient Protection and Affordable Care Act (ACA) similarly required new private health plans to provide no-cost coverage for all FDA-approved contraceptives. [24]


  • 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.[25]
  • Virginia law allows women a full year of birth control covered by insurance vs. the previous 3-month supply. [26]

Available Tools and Resources

  • This brief article provides information on the relative effectiveness of different types of contraceptives and the complexity of choices involved. [27]
  • Project Prevention relies on donations and pays women $300 to get on long-term birth control[28]
  • 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.[29]
  • 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. [30]
  • NEXPLANON is a hormone-releasing birth control implant for use by women to prevent pregnancy for up to 3 years.
  • 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.
  • 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.
  • EmpowerHealth USA provides a telehealth option for contraception counseling.[31]

Promising Practices

The Family Planning Initiative was a four-year project (2005–2009) that delivered contraceptive services to women within a pediatric clinic within a drug treatment facility.Offer contraception planning in non-traditional venues, such as a pediatric clinic within a drug treatment facility. [32] A barrier is staff education and comfort discussing the issue. Education and availability of appropriate staff would be paramount.

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
  • 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. [33]

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. [34] 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. [35]

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. ↑ 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.
  15. ↑ https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud
  16. ↑ https://www.vox.com/2016/3/2/11148108/unplanned-pregnancy-larc-iud
  17. ↑ 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.
  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. ↑ 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
  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. ↑ National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions.
  24. ↑ https://www.patientassistance.bayer.us/
  25. ↑ https://www.regulations.gov/document?D=SAMHSA-2016-0002-0001
  26. ↑ https://lis.virginia.gov/cgi-bin/legp604.exe?212+sum+SB1227
  27. ↑ http://www.latimes.com/health/la-he-0528-birth-control-20160515-snap-story.html
  28. ↑ https://projectprevention.org/
  29. ↑ https://www.tennessean.com/story/news/2017/02/04/iuds-inmates-seen-tool-combat-opioid-crisis/97056396/
  30. ↑ http://www.astepaheadeasttn.org/faq.html
  31. ↑ https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917
  32. ↑ https://doi.org/10.1080/15332985.2011.575723
  33. ↑ https://www.venturenashville.com/empower-health-sets-12m-raise-for-push-into-self-pay-nad-infusion-space-cms-1917
  34. ↑ https://www.patientassistance.bayer.us/
  35. ↑ https://www.patientassistance.bayer.us/
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