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Why women aren’t getting long-acting contraception when they need it most

Mother and baby via

Why are 50% of pregnancies unintended in the US? Why are poor women more likely to have an unplanned pregnancy? One reason is that women can’t get the kind of birth control they want, when they need it.

One of the key times women need reliable contraception is soon after they give birth. More than half of all unintended pregnancies occur within two years after a delivery. These pregnancies are at increased risk of complications such as preterm birth, low birth weight, and stillbirth. And unintended pregnancies have significant social and economic consequences for women, families and communities.

Most women want some form of birth control after they deliver. A sizable proportion of postpartum women – four out of 10 – want long-acting reversible contraception (LARC), like intrauterine devices and contraceptive implants. This is good news, because LARC methods are highly effective. With LARC, the chance of an unplanned pregnancy is less than 1%. Once they are in place, a woman doesn’t have to do anything to make them work, and they are fully reversible, allowing a woman to get pregnant again if she chooses.

But studies show that only about 6% of women at three months postpartum use these methods. That isn’t because of low demand for these methods. In fact, many postpartum women prefer LARC. But up to two-thirds of postpartum women who want to use a LARC method never actually receive it.

Timing issue for women who want LARC

A major roadblock to postpartum LARC is that women generally can’t get it until their routine outpatient postpartum visit (typically scheduled about six weeks after delivery). This is a particular challenge for low-income women, who may not have access to transportation, lack child care, or have unstable insurance coverage – all issues that can make it hard to get to a follow-up appointment. Low-income women are about three times less likely to return for outpatient postpartum care than women from families with higher income.

Offering LARC after birth may help

But there is one strategy to help women get the birth control they want, when they need it most: offer women the option to have a LARC inserted while they are still in the hospital after birth. This is called immediate postpartum LARC (IPLARC).

Insertion while women are still in the hospital is convenient for both patients and health care providers. It reduces periods of time when a woman doesn’t have a contraceptive, and it ensures that women can get their desired contraceptive method before they resume sexual activity. Compared to delayed, outpatient LARC, IPLARC has been shown to decrease unintended pregnancy rates (from 18.6% to 2.6% in one study). What’s more, multiple studies demonstrate IPLARC is actually cost-effective for insurers.

Cheaper, more convenient – what’s the problem?

One potential barrier to IPLARC is that hospitals don’t receive specific payment for it.

Most insurers (including many Medicaid agencies, which cover low-income individuals in many states and pay for nearly half of all births each year in the US) reimburse delivery-related care with one bundled, average payment. There is typically no additional reimbursement for additional services, such as LARC insertion.

Alternatively, if a LARC device is inserted in the outpatient setting, such as at a postpartum visit, insurers typically provide a separate payment for the device and its insertion.

Coverage starting to change

Medicaid programs are catching on to the fact that the traditional bundled payment may prevent some postpartum women from accessing these highly effective forms of contraception. Providing enhanced coverage for IPLARC may help incentive this evidence-based approach to women’s health.

In our recent study published in the journal Contraception, we examined Medicaid coverage of IPLARC. We found that a rapidly increasing number of Medicaid agencies are providing enhanced reimbursement specifically for LARC inserted right after birth. Since 2012, 19 Medicaid programs (18 states and the District of Columbia) have begun to pay specifically for IPLARC. Another eight agencies are considering this type of enhanced coverage. Policymakers in these Medicaid agencies have recognized that IPLARC offers significant health benefits for women and children and overall cost benefits for Medicaid.

Because these enhanced payments are new, it is still too early to know if they have increased used of LARC. However, a recent research study that provided IPLARC at no cost to patients or hospitals demonstrated increased use of LARC and decreased unintended, repeat pregnancy rates in postpartum adolescents. This study suggests that we might see more postpartum women receiving LARC and better health outcomes for women and babies in the parts of the country where Medicaid pays specifically for IPLARC.

But in the remaining 32 states, and among many private insurers, reimbursement is still a major barrier. The most effective forms of birth control remain out of reach to many at-risk postpartum women.

Getting pregnant again too quickly is dangerous for women and children. LARC is a highly effective tool to prevent unintended pregnancy. It is time to make LARC more easily available to all women who want it.

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