By Katherine Rivlin, MD, MSc
Associate Professor, Obstetrics and Gynecology, The Ohio State University Medical Center, Columbus
Using a nationwide sample of insurance claims, researchers found that large declines occurred in contraceptive visits in the first month of the COVID-19 pandemic (April 2020 compared to May 2019). Although visit numbers improved over time, they remained below pre-pandemic levels through the end of 2020.
Steenland MW, Geiger CK, Chen L, et al. Declines in contraceptive visits in the United States during the COVID-19 pandemic. Contraception 2021;104:593-599.
Contraception is a necessary and commonly used preventive health service. From 2017-2019, almost half of reproductive age women in the United States used a contraceptive method that required a healthcare visit.1 Tubal ligations and long-acting reversible contraceptives (LARCs) necessitate in-person services, and methods such as contraceptive pills, patches, and rings traditionally have warranted an in-person assessment prior to initial prescription or even to refill.
The COVID-19 pandemic caused widespread disruption to preventive care services. More than half of OB/GYNs reported seeing fewer patients between March and June 2020, which they attributed to both practice-specific restrictions and patient avoidance of in-person services.2 Although the healthcare system pivoted rapidly to telehealth provision to accommodate this disruption in care, practices varied widely. For example, although reimbursement for telehealth has expanded since the onset of the pandemic, rates vary by state.
An insurance claims study performed in Michigan demonstrated a 72% decline in LARC placement in April 2020 and a 15% to 30% decline in contraceptives obtained from pharmacies in 2020 compared to 2019.3 No similar analysis has occurred on a national level. To fill this gap, this study used data from May 1, 2019, to Dec. 31, 2020, collected from a national insurance claims database covering 280 million patients, 1.8 million prescribers, and 16,000 health plans. The database includes medical claims sent to commercial insurers, Medicaid managed care plans, and state Medicaid programs. The study sample includes patients ages 15 to 45 years who completed at least one contraceptive visit during the study period. It also includes a subgroup of people who gave birth during the study period.
The primary outcome of interest is the overall number of method-specific contraceptive visits. In addition, the team measured the number of method-specific visits among the postpartum cohort and the number of contraceptive telehealth visits performed (which could include pill, patch, or ring prescription). Contraceptive visits were identified using diagnosis and procedure codes, and telehealth visits were identified using digital evaluation codes. Postpartum visits had to occur within 90 days of giving birth, which included contraceptive services prior to hospital discharge. Visits for contraceptive counseling only were excluded. Because of the limitations of claims data, the study team could not explore the role of sociodemographic factors, such as race, ethnicity, income, or rurality.
The team examined immediate changes and sustained changes to contraceptive visits. Immediate change was defined as the number of visits occurring in April 2020 (when all 42 U.S. state and territory stay-at-home orders began and were in place) compared to the number of visits in May 2019 (since complete data were not available from April 2019). Sustained change was defined as visits occurring in December 2020 compared to December 2019.
For postpartum contraception visits, the team assessed individuals who gave birth in February 2020 (whose three-month postpartum time period overlapped with stay-at-home orders) compared to individuals giving birth in May 2019. To measure sustained change for the postpartum cohort, the team compared individuals who gave birth in September 2020 to those who gave birth in September 2019. Within each analysis, the team looked at differences by contraceptive method, age group (adolescents compared to adults), geographic region, and payer type.
Prior to the COVID-19 pandemic, the number of contraceptive visits varied by month, but always were within a consistent range of ± 10%. In April 2020, contraceptive visits for all methods declined dramatically. Compared to May 2019, tubal ligation visits declined by 65% (95% confidence interval [CI], -65.5%, -64.1%); LARC visits declined by 46% (95% CI, -47.0%, -45.6%); contraceptive pill, patch, and ring visits declined by 45% (95% CI, -45.8%, -44.5%); and injectable visits declined by 16% (95% CI, -17.2%, -15.4%).
Sustained declines in contraceptive visits were largest for tubal ligation, with an 18% decline (95% CI, -19.1%, -16.8%) in December 2020 compared to December 2019. Injectable contraception visits declined by 11% (95% CI, -11.4%, -9.6%); LARC visits declined by 6% (95% CI, -6.6%, -4.4%); and pill, patch, and ring visits declined by 5% (95% CI, -5.7%, -3.7%).
By region, immediate declines were greatest in the Northeast and Midwest compared to the South and the West. Sustained declines were similar across all regions. By age, immediate declines were similar between adolescents and adults, although adolescents had a smaller decline in both injectable, pill, patch, and ring visits compared to adults. Although sustained declines for LARC visits remained below December 2019 levels for adults, LARC visits for adolescents actually increased by 18% (95% CI, 14.6%, 21.6%). Similarly, pill, patch, and ring visits increased for adolescents, even as they declined for adults.
In the postpartum cohort, immediate declines were smaller than those observed in the larger sample but still present. Tubal ligation visits decreased by 16% and LARC by 22%. No changes occurred in injectable, pill, patch, or ring visits. Sustained declines remained in tubal ligation visits (9%) and in LARC visits (9%), again with no changes to injectable, pill, patch, or ring visits.
Telehealth visits were rare before March 2020. Between March and April 2020, telehealth visits for the pill, patch, and ring increased by 29.6%. Sustained rates were much lower but still 7.5% higher in December 2020 compared to December 2019. The increase in telehealth visits was similar among all insurance types, but were more sustained in Medicaid users compared to commercial insurance users.
COMMENTARY
This study documents substantial national decreases in contraceptive visits during the COVID-19 pandemic. The declines were most drastic in tubal ligation and LARC visits, since these methods necessitate in-person services. Additionally, tubal ligations typically require an operating room. During the most severe part of the pandemic, many “elective” procedures were delayed to preserve personal protective equipment, and tubal ligation often fell into this category. To compound this, Medicaid requires patients to sign a consent 30 days prior to tubal ligation but did not modify this requirement to allow for electronic or oral signature, thus necessitating additional in-person visits.4
Adolescents were more protected against these declines, and contraceptive visits in this age group even increased over the study time period. Adolescents may be more adept at transitioning to telemedicine visits or may have been more highly prioritized by clinical practices. Telemedicine requires access to an electronic device, internet, and a private space, all of which could pose barriers. Adolescents in particular may have challenges accessing a private space to discuss something as personal as reproductive health. However, these data indicate that the barriers posed by in-person services, such as transportation to a healthcare facility, may be even greater to this age group.
Regionally, immediate declines were greatest in the Northeast and Midwest, perhaps as the result of fewer restrictions around in-person services in the South, or because patients in the Northeast (initially the epicenter of the pandemic) were more likely to avoid in-person services early in the pandemic. Sustained changes were the same across all regions.
This study demonstrates the central role that telemedicine played in continuing to provide preventive services when in-person visits were limited.5 Although contraceptive telemedicine services increased dramatically in the first months of the pandemic, the numbers have declined since that time. This study cannot answer if this decline is the result of less telemedicine availability or a decline in patient demand for telemedicine services. Further research into patient preferences around telemedicine is necessary, and healthcare facilities should continue to adapt these services to patient needs. Additionally, payment parity for telemedicine visits is critical, including audio-only visits so that patients without internet access can continue to receive these services.
This study provides vital information to practicing clinicians not just to anticipate potential future restrictions to in-person services, but also to better meet the needs of our patients, even under “normal” circumstances. To provide our patients with the full range of contraceptive options, we must recognize and acknowledge that the pandemic simply magnified barriers to care that already existed.
Medicaid 30-day waiting periods restrict access to tubal ligation, even outside of a pandemic. Many patients do not need an in-person assessment for a birth control refill, and telehealth expands contraceptive access, whether or not stay-at-home orders are in place. Better understanding our patients’ needs and preferences is vital to providing contraceptive autonomy and patient-centered care.
REFERENCES
- Daniels K, Abma JC. Current contraceptive status among women aged 15-49: United States, 2017-2019. NCHS Data Brief 2020; Oct:1-8.
- Weigel G, Frederiksen B, Ranji U, Salganicoff A. How OBGYNs adapted provision of sexual and reproductive health care during the COVID-19 pandemic. Kaiser Family Foundation. Published Dec. 2, 2020. https://www.kff.org/womens-health-policy/issue-brief/how-obgyns-adapted-provision-of-sexual-and-reproductive-health-care-during-the-covid-19-pandemic/
- Becker NV, Moniz MH, Tipirneni R, et al. Utilization of women’s preventive health services during the COVID-19 pandemic. JAMA Health Forum 2021;2:e211408.
- Evans ML, Qasba N, Shah Arora K. COVID-19 highlights the policy barriers and complexities of postpartum sterilization. Contraception 2021;103:3-5.
- Weigel G, Frederiksen B, Ranji U, Salganicoff A. Telemedicine in sexual and reproductive health. Kaiser Family Foundation. Published Nov. 22, 2019. https://www.kff.org/womens-health-policy/issue-brief/telemedicine-in-sexual-and-reproductive-health/
