From Coverage to Culture, Researchers Discuss Barriers to Long-Acting Contraception

Long-acting reversible contraception (LARC) is widely recommended for preventing unwanted pregnancies, as it does not require women to remember to take a pill every day. In recent years, the American Academy of Pediatrics recommended it to prevent teenage pregnancy, which the Guttmacher Institute reports has plummeted in the United States in recent decades, thanks to wider use of contraception.

The availability of contraception under the Affordable Care Act (ACA) promised to further drive down unintended pregnancy. However, researchers at a media session Friday during the annual meeting of the American College of Obstetricians and Gynecologists (ACOG) said barriers from geography to payer coverage to health institutions mean access still depends on where a woman lives.

Chelsea Bayer, MD, an obstetrician/gynecologist at Washington University in Saint Louis, Missouri, discussed 1 of 2 abstracts she is presenting at ACOG, which concerned women on Medicaid who were recruited for a program that would allow them to receive LARC immediately postpartum with full reimbursement, to prevent further unintended pregnancies in women who were at risk of being lost to postpartum follow-up care. The women could receive either an intrauterine device (IUD) or an implant insertion before being discharged from the hospital. The IUD was inserted immediately post placenta. Bayer explained that the women were counseled about the advantages of LARC during their pregnancy care, a step that became more important when Medicaid began requiring prior authorization for LARC.

“Unintended pregnancies are associated with maternal depression, limited access to maternal care, financial burden, and in the case of short interval unintended pregnancies, increased risk of preterm delivery,” the authors wrote. Having access to fully funded LARC creates the opportunity for contraception with the risks associated with being lost to follow-up care, they said.

According to the abstract, 65 women were classified as lost to postpartum follow-up care, which was defined as failing to show for a postpartum appointment and being unreachable by phone. Of this group, 24 had been discharged with LARC in place, 23 did not have a form of contraception, and 18 had a non-LARC form of contraception. Of the group, 96% had received immediate postpartum LARC had been given information about during prenatal care or during labor, compared with 56% who chose an alternate method.¹

Bayer is also a co-author on a second abstract that shows the importance of reimbursement for poor women in making contraception choices. A survey of 178 women included 70 who responded before Medicaid changed its policy to pay for LARC, and 108 after reimbursement began. Women were 2.5 times more likely to use LARC postpartum birth control immediately after giving birth once reimbursement began. Of the 49 women who chose LARC after the policy change, 42 (86%) received the method before hospital discharge.²

But barriers to LARC persist. Megan L. Evans, MD, MPH, of Tufts Medical Center in Boston, presented results of an anonymous survey of residents from across the country with an extraordinarily high response rate of 99%, because it was done in tandem with the 2016 CREOG in-service exam. Evans and her co-authors were also able to get responses by region, which shed light on how cultural and religious resistance at some institutions play a role in some residents being unwilling to learn to insert LARC, or not having access to the contraception because of institution policies. Evans’ survey found:

• As of January 2016, 32% of all residents had inserted between 1 and 10 IUDs and 31.7% had inserted 11 to 25 IUDs; 39.6% residents had inserted 1 to 10 contraceptive implants. For separate research, she found that residents using IUDs themselves were more likely to insert IUDs.
• Training is a problem in some locations: 8% of chief residents had never inserted an implant and 10% had inserted 1-10 IUDs.
• Nearly a third of all residents and 40% of all Southern residents identified financial barriers, including the cost of the device that prevents it from being stocked, inadequate coverage among the patient population, and lack of training.
• Religious affiliation of the institution was a significant barrier in the Midwest, where 27% of residents reported this issue, compared with 6.4% of residents elsewhere.³

Finally, Kristen Lilja, MD, and her co-authors did a “mystery caller” phone survey to gauge the availability of the copper IUD in both urban and rural clinics in Washington state over a 2-month period. The same caller used a standard script, calling OB/GYN, primary care, family planning, and multispecialty clinics. Lilja said the copper IUD was selected because of its potential use in both long-term and emergency contraception.

A total of 97 urban and 97 rural clinics were included, and the copper IUD was available in 78 urban clinics, compared with 50 rural clinics. Only 19 urban clinics and 10 rural clinics were able to schedule an appointment for copper IUD placement within a 5-day window, which would be needed if the device would be needed for emergency contraception. The lack of availability in rural clinics was the same even when clinic type was taken into account, the authors found.⁴

References

1. Bayer C, Paul R, Braun E, et al. Uptake of immediate postpartum LARC in women at risk of loss to follow up. Presented at the Annual Meeting of the American College of Obstetricians and Gynecologists; Austin, Texas; April 27-30, 2018, abstract 21G.
2. Paul R, Bayer C, Braun E, et al. Immediate postpartum LARC reimbursement increases uptake of effective contraception after pregnancy. Presented at the Annual Meeting of the American College of Obstetricians and Gynecologists; Austin, Texas; April 27-30, 2018, abstract 22G.
3. Evans ML, Espev E, et al. Barriers to LARC training in OB/GYN residencies. Presented at the Annual Meeting of the American College of Obstetricians and Gynecologists; Austin, Texas; April 27-30, 2018, abstract 140P.
4. Lilja K, Infante S, Micks E. The impact of rural or urban location on clinical availability of the copper IUD: a mystery caller study. Presented at the Annual Meeting of the American College of Obstetricians and Gynecologists; Austin, Texas; April 27-30, 2018, abstract 14F.