EXECUTIVE SUMMARY

The success of the Contraceptive CHOICE Project in removing financial barriers to contraception, promoting the most effective methods of birth control, and reducing unintended pregnancy is no longer an isolated event.

  • A program designed to prevent unintended pregnancies and reduce birth defects during the height of the 2016-17 Zika virus outbreak in Puerto Rico provided women a full range of contraceptive options, free of charge, on the same day of their initial clinic visit. Of those women receiving a long-acting method, 75.8% had used no method or a less effective method (such as condoms or withdrawal) prior to their visit.
  • A new study from researchers at the University of Utah Health provided no-cost contraception to 7,400 women and enrolled more than 4,400 women in the three-year study. Researchers report that with costs removed, women chose more effective contraceptive methods such as the intrauterine device.

In 2007, researchers at the Washington University School of Medicine in St. Louis initiated a cohort study of nearly 10,000 women that aimed to remove the financial barriers to contraception, promote the most effective methods of birth control, and reduce unintended pregnancy in the St. Louis area.

Results of the Contraceptive CHOICE Project have shown that:

  • Long-acting reversible contraception (LARC) makes an impact on unintended pregnancy. Women using either the intrauterine device (IUD) or the contraceptive shot had the lowest unintended pregnancy rates during year 1, year 2, and year 3 of their follow-up. Pill, patch, and ring users had much higher unintended pregnancy rates; they were 20 times more likely to have an unintended pregnancy compared to LARC users in year 1.1,2
  • Women who choose LARC methods tend to stick with their chosen option. Among women who chose a LARC method in the Contraceptive CHOICE Project, 86% were still using the method at one year. For women who chose a non-long-acting method, only 55% were still using their method at a similar time point.3
  • Once financial barriers are removed and long-acting reversible methods of contraception are introduced as a first-line contraceptive option, most women will choose LARC methods. Seventy-five percent of women in the Contraceptive CHOICE Project chose one of the three LARC methods (46% levonorgestrel intrauterine system, 12% copper intrauterine device, and 17% subdermal implant).4

The success of the Contraceptive CHOICE Project is no longer an isolated event. Family planning clinicians throughout the nation are finding new ways to implement similar principles.

Providing Protection in Puerto Rico

A program designed to prevent unintended pregnancies and reduce birth defects during the height of the 2016-17 Zika virus outbreak in Puerto Rico provided women a full range of contraceptive options, free of charge, on the same day of their initial clinic visit.5 With such access, two-thirds of women at risk of unintended pregnancy chose LARC methods.

Preliminary analysis of the Zika Contraception Access Network (Z-CAN) indicate more than 21,000 women were served during its 16-month period. The project was supported by the CDC Foundation, with technical assistance from the Centers for Disease Control and Prevention (CDC). Led by Eva Lathrop, MD, MPH, associate professor in the department of gynecology and obstetrics at Emory University School of Medicine and in Rollins School of Public Health’s Department of Global Health, Z-CAN was established in May 2016. Lathrop served as the lead for contraception on the Pregnancy and Birth Defects Task Force during the CDC’s Zika response efforts. Denise Jamieson, MD, MPH, and Erin Berry-Bibee, MD, MPH, both with Emory’s Department of Gynecology and Obstetrics, also worked with the Z-CAN program.

During the outbreak, Puerto Rico recorded the highest number of symptomatic Zika virus infections in the United States and U.S. territories. Many women were at risk for unintended pregnancy, and more than 50% of pregnancies in Puerto Rico were unintended in 2016, researchers report.5

During the project, 21,124 women received contraceptive services from a network of 153 specially trained providers in 140 established Puerto Rico clinics with gynecology and obstetrics services. All Z-CAN services were provided free of charge.

Researchers report 95% of those women received a contraceptive method on the day of their initial Z-CAN visit. While just 4% used a LARC method prior to Z-CAN, 67.5% chose and received a LARC method at their initial visit. Of those women who received a LARC method, 75.8% had used no method or a less effective method (such as condoms or withdrawal) prior to their visit.5

“Prior to Z-CAN, there were numerous barriers that limited women’s access to contraception,” says Lathrop. “Through Z-CAN, we were able to reduce these barriers and give women who wanted to prevent pregnancy access to the contraceptive method of their choice, including long-acting reversible contraception, such as intrauterine devices and contraceptive implants.”

Removing Cost Barrier Makes Impact

Results of a new study from researchers at the University of Utah Health find that cost often limits women’s access to the most effective contraceptive methods, such as IUDs and subdermal implants. The HER (Highly Effective Reversible) Salt Lake Contraceptive Initiative was designed to evaluate women’s contraception choices if cost is not a factor.6 When cost barriers were removed in Salt Lake County, IUD and implant uptake more than doubled, from 20% to 44%.

In addition to removing cost as an obstacle, the program made all forms of contraceptive available. Women could change methods at any time in the study, free of charge.

Researchers designed the study in three six-month segments: a control, Intervention 1, and Intervention 2. The control period served as the baseline for the study, evaluating the birth control methods selected by women who received standard contraceptive counseling and care at Planned Parenthood clinics throughout Salt Lake County. In Intervention 1, women seeking services at participating clinics were offered no cost, same-day access to the reversible contraceptive method of their choice, and could change their choice at any time during the three-year study. Those women enrolled in Intervention 2 received the same care as the first intervention, as well as education about contraceptives through an online media campaign.

The program provided no-cost contraception to 7,400 women and enrolled more than 4,400 women in the three-year study. Researchers report that women in Intervention 1 were 1.6 times more likely to use an IUD and 2.5 times more likely to use an IUD in Intervention 2 compared to those who enrolled during the control period.6

“When you remove cost as a factor, people are more likely to select more effective contraception methods that are often the most expensive up front,” says Jessica Sanders, PhD, MSPH, lead author and research assistant professor in obstetrics and gynecology at University of Utah Health. “When we added education and outreach to the picture, we saw an increase in the demand for these methods.”

While the Affordable Care Act (ACA) calls for insurance plans to cover all approved methods of contraception at no cost, research indicates about one in 10 women remain uninsured, either due to finances, documentation, or lack of knowledge of the requirement to buy insurance.7 While Medicaid covers birth control, only about half of doctors in 2015 were accepting new Medicaid patients.8 Also, 19 states have yet to expand Medicaid under the ACA.8

Women who rely on Title X publicly funded services have faced challenges as well. Texas is one of several states that have prohibited Planned Parenthood affiliates from providing healthcare services with the use of public funds. Following the federal government’s refusal to allow the exclusion of Planned Parenthood affiliates from the Texas Medicaid fee-for-service family-planning program, the state struck them from participating in a state-funded replacement program (Texas Women’s Health Program) effective January 1, 2013. Research indicates that program claims for long-acting reversible contraception dropped by one-third following the exclusion.9

REFERENCES

  1. Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120:1291-1297.
  2. McNicholas C, Madden T, Secura G, Peipert JF. The Contraceptive CHOICE Project round up: What we did and what we learned. Clin Obstet Gynecol 2014;57:635-643.
  3. Diedrich JT, Zhao Q, Madden T, et al. Three-year continuation of reversible contraception. Am J Obstet Gynecol 2015;213:662.e1-8.
  4. Birgisson NE, Zhao Q, Secura GM, et al. Preventing unintended pregnancy: The Contraceptive CHOICE Project in review. J Womens Health (Larchmt) 2015;24:349-353.
  5. Lathrop E, Romero L, Hurst S, et al. The Zika Contraception Access Network: A feasibility programme to increase access to contraception in Puerto Rico during the 2016-17 Zika virus outbreak. Lancet Public Health 2018;3:e91-e99.
  6. Sanders JN, Myers K, Gawron LM, et al. Contraceptive method use during the community-wide HER Salt Lake Contraceptive Initiative. Am J Public Health 2018;108:550-556.
  7. Kaiser Family Foundation. Women’s health insurance coverage. Fact sheet. Oct. 31, 2017. Available at: http://kaiserf.am/2hBuhob. Accessed March 16, 2018.
  8. Kaiser Family Foundation. Status of state action on the Medicaid expansion decision. Available at: http://kaiserf.am/2ApqilS. Accessed March 16, 2018.
  9. Stevenson AJ, Flores-Vazquez IM, Allgeyer RL, et al. Effect of removal of Planned Parenthood from the Texas Women’s Health Program. N Engl J Med 2016;374:853-860.