In recent years, studies have shown the benefits of same-day contraception access. But practice has not always caught up with research.1
“All research is showing the benefits of having all options for women,” says Tracey A. Wilkinson, MD, MPH, assistant professor of pediatrics at Indiana University School of Medicine. The standard practice was for women to return for their contraceptive method — particularly for long-acting reversible contraceptives (LARCs), she says.
Investigators wanted to find out how successful providers were at getting patients to return for their chosen contraceptive.
“That’s where the study design came from, and it was much more complicated than we thought,” Wilkinson says. “While over half of people did get the desired form of contraception eventually, the amount of work and referral to get it done was not an easy lift.”
Women face additional costs and logistics when providers do not give them access to same-day contraception. “It’s easy for someone to say, ‘This LARC device costs $900, and it’s too expensive to stock in our clinic,’” Wilkinson explains.
But it also is costly to for staff to conduct follow-up on referrals and to file insurance paperwork to see if the device is covered. “Each patient is a huge lift for our clinical system, and every time there’s a step, people fall through the cracks,” Wilkinson says.
The clinical system the researchers examined did not stock any LARC. This is a problem. But it also is problematic if a clinic stocks only certain types of LARC.
“That doesn’t put all the forms of contraception on the same playing field,” Wilkinson says. “Our job is to approach this from the perspective of a reproductive justice framework, where all options are there equally, and we let the patient decide what’s important to them.”
Ideally, clinics would treat contraceptive care like primary care, making an effort to have as many options available as possible, she says.
“Access is what we need to focus on,” Wilkinson says. “There are plenty of providers and clinics that want to provide contraceptives, but [barriers are] the logistics of insurance approval, stocking the device, and clinic supply ordering.”
Even with the Affordable Care Act (ACA) improving contraception access for many women, insurance remains a significant barrier. One-third of unsuccessful contraception referrals involved insurance issues, Wilkinson says.
“Every clinic checks the person’s insurance before ordering the expensive device,” she explains. “We now have multiple versions of hormonal IUDs [intrauterine devices], so someone’s insurance may cover one type of IUD and not another.”
Plus, the U.S. Supreme Court decided a contraceptive access case in favor of employers, saying they do not have to provide contraceptive coverage if it goes against their moral beliefs.
“It’s not unheard of for people to be working at institutions that say they have a moral disagreement with contraception, and the employee may not know this until contraception is requested,” Wilkinson says. “Now, we have a landscape where it’s not as universally [true] that your insurance is going to cover it.”
Some healthcare facilities will provide contraceptive services and absorb the cost if insurance billing is unsuccessful. “Or, they may have figured out a way around it, but that takes will, motivation, commitment,” she adds. “You could have five or six people whose IUDs are not covered, and you’re talking about thousands of dollars.”
This is unaffordable for many healthcare organizations that serve a poor and uninsured population. “They have to keep their doors open,” Wilkinson says.
Data showed less-than-ideal outcomes for patients who had to return for their device when it was not available on the same day. “We’re not doing a good job of taking care of patients who expressed a desire for pregnancy prevention,” she says.
Another barrier involves low rates of bridge contraception. “Counseling on bridge contraception is very low,” Wilkinson adds. “We had some people in our cohort who came back for an IUD, and it turned out they were pregnant.”
The same people had said they did not want to become pregnant, but they walked out of their first clinic visit with just a referral — instead of a contraceptive method to bridge the time before they could have the IUD inserted.
“We found the average number of days between referral and placement is about a month,” Wilkinson says.
This barrier can be resolved easily, with the clinician offering the patient a birth control method to use until they return for the LARC. The clinic can make a follow-up call to check on the patient obtaining a contraceptive.
Also, clinics often do not schedule follow-up appointments until they receive insurance approval. There should be a tracking system in place to make it easier to follow the referrals, ensuring no one falls between the cracks, Wilkinson says.
“Just like I have an alert in my system when someone has been waiting for over an hour, maybe there could be an alert when someone has not been scheduled in X number of days,” she says. “Maybe you could reach out to that patient and they say, ‘I never heard anything.’”
Or, maybe the patient decided against a particular contraception, so the provider can offer a different method.
“If you have a patient who says, ‘I don’t have a partner right now, and I am not having sex,’ then you could say, ‘Great — let me give you emergency contraception or condoms, in case that changes,’ or ‘Here is a birth control patch you can use until your IUD is in,’” Wilkinson says.
Another barrier involves clinic protocols that are not evidence-based. “Make sure your clinic protocols are as up to date as the guidelines are,” she says. “You shouldn’t have different levels of care based on what clinic you’re at.”
Protocols should address IUD removal as well. “If a LARC device is not a good fit for them, there should be zero barriers for removal,” Wilkinson says. “There’s a huge problem with that. As a community, we have to stop that immediately.”
It is important for providers to validate patients’ concerns, while also providing them with evidence-based information and contraceptive counseling that mentions common side effects and what can be done about them.
“We have to start treating reproductive healthcare like it’s a guarantee for everybody — men, women, everybody,” Wilkinson says. “Why don’t we have tools to let people have children when they want them?”
There needs to be governmental commitment, accompanied with policy changes. “Reproductive healthcare has been politicized,” Wilkinson says. “Politics have come into science about medical care, and politics should stay out of science and medicine.”
Robert Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, notes, “Everything we have learned about the delivery of contraceptive services suggests they should be available to every woman who wants it on the first visit after they have been told all the contraceptive options. Ideally, the cost should be zero.”
REFERENCE
- Wilkinson TA, Edmonds BT, Cheng ER. Outcomes of a two-visit protocol for long-acting reversible contraception for adolescents and young adults. Contraception 2021;S0010-7824(21)00341-3.
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