Patient Education About the Affordable Care Act Contraceptive Coverage Requirement Increases Interest in Using Long-Acting Reversible Contraception

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Role of User Benefit Awareness in Health Coverage Utilization among the Poor in Cambodia

The objective of this study was to understand the steps to health coverage benefit utilization in Cambodia toward improving access to health care and financial risk protection for the poor. We particularly examine the role of user awareness in the pathway to care seeking and benefit utilization with respect to the Health Equity Funds (HEF). Using 2016 survey data that were nationally representative of households with children under two years of age, we used a series of logistic regression models to evaluate associations between respondents' awareness of benefits, public health care seeking behaviors, coverage benefit claims, and out-of-pocket expenditures. Beneficiaries were generally aware of their entitlements, although their awareness of specific benefits, such as transport reimbursement, was relatively lower. Awareness of free services at public health centers was associated with twice the odds of having ever visited a public provider for outpatient care, while awareness of free services at public hospitals was associated with higher odds of always seeking inpatient care in the public sector. Study findings point to the decision of where to seek care as the critical point in the pathway to HEF utilization. If the decision had already been made to go to a public provider, it was likely that HEF benefits were claimed. Interventions that prompt appropriate care seeking in the public sector may do the most to improve HEF utilization and subsequently improve access to care through sufficient financial risk protection.

Contraceptive Use Among Women in the United States Aged 18-44 Years with Selected Medical Contraindications to Estrogen

Objective: Medical contraindications to estrogen limit women's contraceptive options. This study assessed the association between selected medical contraindications to estrogen on contraceptive use and examined whether contraindications serve as a barrier to the prevention of unintended pregnancy. Materials and Methods: We analyzed women aged 18-44 at risk of unintended pregnancy participating in the 2017 Behavioral Risk Factor Surveillance System. Survey questions queried women regarding contraceptive use and contraindications to estrogen use. We assessed the most recently used contraceptive method and compared the odds of women using each category of contraception (no methods, less effective methods, pill/patch/ring, injection, intrauterine device, implant, permanent contraception) between those with and without potential contraindications to estrogen using multinomial logistic regression models. Results: This study included 32,098 women, of whom 16% had one or more potential contraindications to estrogen. There were significant differences in contraceptive choice by potential contraindication status (p < 0.01). Fifteen percent of women with potential contraindications reported using estrogen-containing methods (pill, patch, or ring) compared with 20% of women with no potential contraindication. Women with potential contraindications to estrogen more frequently used permanent contraception (odds ratio [OR] vs. pill/patch/ring: 1.48 95% confidence interval [CI]: 1.17-1.88) or no contraceptive method (OR vs. pill/patch/ring: 1.37 95% CI: 1.07-1.75) after adjustment for race, age, marital status, and income. Conclusions: Potential medical contraindications to estrogen are associated with permanent contraception and the use of no contraception. These results portray a complicated relationship but could suggest a lack of access to other contraceptive options.

Evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative: A qualitative analysis of site leaders' implementation recommendations

OBJECTIVES

In 2014, Delaware launched a statewide initiative to reduce the rate of unintended pregnancies and increase access to contraception services. Our study objective was to understand the implementation experiences, barriers, and successes across health care practice settings and to provide recommendations for future, similar initiatives.

STUDY DESIGN

As part of a larger multicomponent process evaluation, we conducted semistructured interviews with 32 leaders from 26 practice settings implementing the initiative across the state. We analyzed the qualitative data through iterative open, axial, and selective coding using grounded theory methods, employing thematic analysis to identify common themes in implementation experiences.

RESULTS

Most practices perceived that patient demand for methods of long-acting reversible contraception (LARC) increased. Many practices had to adapt the intervention to fit the needs and constraints of their settings and patient populations. Primary care practices, smaller practices, and practices that served large numbers of adolescents experienced more barriers compared to obstetrics and gynecology or women's health practices. For current and future iterations of the initiative, leaders emphasized: (1) the need for greater implementation flexibility, (2) the importance of inclusive communication at multiple levels, and (3) attending to logistical challenges, particularly around billing.

CONCLUSION

Varied practice settings required significant flexibility and responsiveness to context in order to implement the initiative. Organizations with greater pre-existing capacity were able to offer the full range of contraceptive care, as the initiative intended, in contrast to practices with less pre-existing capacity for providing methods of LARC and other types of contraception.

IMPLICATIONS

To meet the specific but heterogenous needs of various practices, it is crucial for future contraceptive access initiatives to conduct a comprehensive pre-implementation assessment. Preceding any training, this assessment should gather input from participants across all roles in a medical practice (e.g., providers, medical assistants, office staff, billing department).

Dual-Method Contraception Use Among Young Women Pre- and Post-ACA Implementation

The 2012 implementation of the Patient Protection and Affordable Care Act (ACA) contraceptive coverage mandate removed financial barriers to contraception access for many insured women. Since that time, increases in sexually transmitted disease (STD) rates have been noted, particularly among Black adolescent and young adult women aged 15 to 24 years. It is unclear whether changes in dual-method contraception use (simultaneous use of nonbarrier contraceptive methods and condoms) are associated with the increase in STD rates. A repeated cross-sectional analysis was conducted among adolescent and young adult women to compare pre-ACA data from the 2006-2010 cohort and post-ACA data from the 2013-2015 cohort of the National Survey for Family Growth. A significant decrease in short-acting reversible contraception use (SARC; 78.2% vs. 67.5%; p < .01) and a significant increase in long-acting reversible contraception use (LARC; 8.9% vs. 21.8%; p < .01) were found, but no significant change in dual-method contraception use was found among pre- versus post-ACA SARC users and SARC nonusers (odds ratio [OR]: 1.88, 95% confidence interval [CI]: 0.64-5.46, p = .25), LARC users and LARC nonusers (adjusted odds ratio [AOR]: 1.62, 95% CI: 0.42-6.18, p = .48), or White and Black women (AOR: 1.45, 95% CI: 0.66-3.18, p = .35). There was no direct association between changes in contraception use and decreased condom use and therefore no indirect association between changes in contraception use and increased STD rates. Health care providers should continue promoting consistent condom use. Additional research is needed to understand recent increases in STD rates among Black women in the post-ACA era.

“Repeal and replace”: increased demand for intrauterine devices following the 2016 presidential election

OBJECTIVE

To evaluate public's interest in contraceptive options following heightened focus on a repeal of the Affordable Care Act (ACA) since the 2016 United States presidential election.

STUDY DESIGN

We monitored the fraction of Google searches emerging from the United States for the three most popular reversible contraceptive methods - oral contraceptives, intrauterine devices (IUDs) and condoms - from January 1, 2004, through October 31, 2017 (1 year after the presidential election).

RESULTS

IUD searches were cumulatively 15% (95% CI: 10 to 20) higher than expected the year following the 2016 election, reflecting 10 to 21 million excess searches. IUD searches were statistically significantly higher in all states, except NV, and were consistent across states won by Trump or Clinton (Welch t test=0.60, p=.548). Conversely, searches for oral contraceptives and condoms remained stable (0%; 95% CI: -2 to 1) or declined (-4%; 95% CI: -5 to -2), respectively, following the election.

CONCLUSIONS

The etiology of increased searches for IUDs is likely multifaceted. However, it may largely be because IUDs will confer continued protection even after an ACA repeal, thereby providing a medical hedge against a possible repeal. Regardless, these data suggest the heightened focus on an ACA repeal is a concern to the record number of Americans seeking out information about IUDs.