Strategies and safeguards to ensure access to long-acting reversible contraception removal after the Zika Contraception Access Network ended: A prospective analysis of patient reported complaints

Long-acting reversible contraception use and unmet desire among patients after the Zika Contraception Access Network Program in Puerto Rico

OBJECTIVES

To describe unmet desire for long-acting reversible contraception (LARC) after the Zika Contraception Access Network (Z-CAN) in Puerto Rico during the 2016-2017 Zika outbreak.

STUDY DESIGN

Z-CAN patients completed surveys about contraception experiences over a 3-year period.

RESULTS

Of 1809 respondents, 3% never used LARC but reported wanting it since their initial visit. As reasons for not getting LARC, nearly 50% indicated a provider-related reason and 25% reported cost.

CONCLUSIONS

Few Z-CAN patients who never used LARC had unmet desire. Provider training in contraception guidelines and strategies to address costs can expand access to the full range of reversible contraception.

IMPLICATIONS

Three years after a short-term program provided reversible contraception in Puerto Rico, few respondents had never used but wanted a long-acting reversible contraception method. Nearly half reported provider-related reasons for not receiving long-acting reversible contraception, and 25% reported cost. Provider awareness of contraceptive guidance and method availability can support client-centered care.

Continuation of Reversible Contraception Following Enrollment in the Zika Contraception Access Network (Z-CAN) in Puerto Rico, 2016-2020

The Zika Contraception Access Network (Z-CAN) provided access to high-quality client-centered contraceptive services across Puerto Rico during the 2016-2017 Zika virus outbreak. We sent online surveys during May 2017-August 2020 to a subset of Z-CAN patients at 6, 24, and 36 months after program enrollment (response rates: 55-60 percent). We described contraceptive method continuation, method satisfaction, and method switching, and we identified characteristics associated with discontinuation using multivariable logistic regression. Across all contraceptive methods, continuation was 82.5 percent, 64.2 percent, and 49.9 percent at 6, 24, and 36 months, respectively. Among continuing users, method satisfaction was approximately ≥90 percent. Characteristics associated with decreased likelihood of discontinuation included: using an intrauterine device or implant compared with a nonlong-acting reversible contraceptive method (shot, pills, ring, patch, or condoms alone); wanting to prevent pregnancy at follow-up; and receiving as their baseline method the same method primarily used before Z-CAN. Other associated characteristics included: receiving the method they were most interested in postcounseling (6 and 24 months) and being very satisfied with Z-CAN services at the initial visit (6 months). Among those wanting to prevent pregnancy at follow-up, about half reported switching to another method. Ongoing access to contraceptive services is essential for promoting reproductive autonomy, including supporting patients with continued use, method switching, or discontinuation.

Perceptions of the Zika Virus, Contraceptive Access, and Motivation to Participate in the Zika Contraception Access Network Program: Qualitative Analysis of Focusgroup Discussions with Puerto Rican Women

OBJECTIVE

During the 2016-2017 Zika virus outbreak in Puerto Rico, the Zika Contraception Access Network (Z-CAN) provided client-centered contraceptive counseling and access to the full range of reversible contraceptive methods at no cost to prevent unintended pregnancies and thereby to reduce Zika-related birth outcomes.

METHODS

To understand how Puerto Rican women's perceptions of the Zika virus affected contraceptive decisions and assess how they heard about the Z-CAN program and what influenced their participation, or lack thereof, 24 focus-group discussions were conducted among women of reproductive age who did and did not participate in Z-CAN.

RESULTS

Women who participated in the discussions often had heard about Z-CAN from their physician or friends; non-participants had heard about Z-CAN from Facebook or friends. Women expressed satisfaction on finding a Z-CAN clinic and valued the same-day provision of contraceptives. When a preferred contraceptive method or a first appointment was not readily available, women reconsidered accessing the program. Women's perceptions and trust of reproductive healthcare providers, their engagement in social networks, and their ability to choose a contraceptive method that best meets their needs can influence participation in contraception-access programs.

CONCLUSION

Focus groups can be used to understand women's knowledge of the Zika virus, barriers and facilitators to contraception access, and motivations for participation in the Z-CAN program.

Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020

OBJECTIVE

We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic.

METHODS

We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth.

RESULTS

Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020.

CONCLUSIONS

Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.

Prevalence of non-preferred family planning methods among reproductive-aged women in Burkina Faso: results from a cross-sectional, population-based study

Family planning researchers have traditionally focused efforts on understanding contraceptive non-use and promoting contraceptive uptake. Recently, however, more scholars have been exploring method dissatisfaction, questioning the assumption that contraceptive users necessarily have their needs met. Here, we introduce the concept of "non-preferred method use", which we define as the use of one contraceptive method while having the desire to use a different method. Non-preferred method use reflects barriers to contraceptive autonomy and may contribute to method discontinuation. We use survey data collected from 2017 to 2018 to better understand non-preferred contraceptive method use among 1210 reproductive-aged family planning users in Burkina Faso. We operationalise non-preferred method use as both (1) use of a method that was not the user's original preference and (2) use of a method while reporting preference for another method. Using these two approaches, we describe the prevalence of non-preferred method use, reasons for using non-preferred methods, and patterns in non-preferred method use by current and preferred methods. We find that 7% of respondents reported using a method they did not desire at the time of adoption, 33% would use a different method if they could and 37% report at least one form of non-preferred method use. Many women cite facility-level barriers, such as providers refusing to give them their preferred method, as reasons for non-preferred method use. The high prevalence of non-preferred method use reflects the obstacles that women face when attempting to fulfil their contraceptive desires. Further research on reasons for use of non-preferred methods is necessary to promote contraceptive autonomy.

Economic evaluation of Zika Contraception Access Network in Puerto Rico during the 2016-17 Zika virus outbreak

OBJECTIVE

During the 2016-2017 Zika virus (ZIKV) outbreak, the prevention of unintended pregnancies was identified as a primary strategy to prevent birth defects. This study estimated the cost-effectiveness of the Zika Contraception Access Network (Z-CAN), an emergency response intervention that provided women in Puerto Rico with access to the full range of reversible contraception at no cost and compared results with a pre-implementation hypothetical cost-effectiveness analysis (CEA).

STUDY DESIGN

We evaluated costs and outcomes of Z-CAN from a health sector perspective compared to no intervention using a decision tree model. Number of people served, contraception methods mix, and costs under Z-CAN were from actual program data and other input parameters were from the literature. Health outcome measures included the number of Zika-associated microcephaly (ZAM) cases and unintended pregnancies. The economic benefits of the Z-CAN intervention were ZIKV-associated direct costs avoided, including lifetime medical and supportive costs associated with ZAM cases, costs of monitoring ZIKV-exposed pregnancies and infants born from Zika-virus infected mothers, and the costs of unintended pregnancies prevented during the outbreak as a result of increased contraception use through the Z-CAN intervention.

RESULTS

The Z-CAN intervention cost a total of $26.1 million, including costs for the full range of reversible contraceptive methods, contraception related services, and programmatic activities. The program is estimated to have prevented 85% of cases of estimated ZAM cases and unintended pregnancies in the absence of Z-CAN. The intervention cost was projected to have been more than offset by $79.9 million in ZIKV-associated costs avoided, 96% of which were lifetime ZAM-associated costs, as well as $137.0 million from avoided unintended pregnancies, with total net savings in one year of $216.9 million. The results were consistent with the previous CEA study.

CONCLUSION

Z-CAN was likely cost-saving in the context of a public health emergency response setting.

The Role of Public-Private Partnerships to Increase Access to Contraception in an Emergency Response Setting: The Zika Contraception Access Network Program

The Zika Contraception Access Network (Z-CAN) program was a short-term emergency response intervention that used contraception to prevent unintended pregnancies to reduce Zika-related adverse birth outcomes during the 2016-2017 Zika virus outbreak in Puerto Rico. The Centers for Disease Control and Prevention (CDC) reported that a collaborative and coordinated response was needed from governments and private-sector partners to improve access to contraception during the Zika outbreak in Puerto Rico. In response, the National Foundation for the CDC, with technical assistance from CDC, established the Z-CAN program, a network of 153-trained physicians, that provided client-centered contraceptive counseling and same-day access to the full range of the Food and Drug Administration-approved reversible contraceptive methods at no cost for women who chose to prevent pregnancy. From May 2016 to September 2017, 29,221 women received Z-CAN services. Through Z-CAN, public-private partnerships provided a broad range of opportunities for partners to come together to leverage technical expertise, experience, and resources to remove barriers to access contraception that neither the public nor the private sector could address alone. Public-private partnerships focused on three areas: (1) the coordination of efforts among federal and territorial agencies to align strategies, leverage resources, and address sustainability; (2) the mobilization of private partnerships to secure resources from private corporations, domestic philanthropic organizations, and nonprofit organizations for contraceptive methods, physician reimbursement, training and proctoring resources, infrastructure costs, and a health communications campaign; and (3) the engagement of key stakeholders to understand context and need, and to identify strategies to reach the target population. Public-private partnerships provided expertise, support, and awareness, and could be used to help guide programs to other settings for which access to contraception could improve health outcomes.