Scaling Up Evidence-Based Practices in Contraceptive Access Initiatives

Contraception can play a critical role in individuals’ achievement of personal health, social, and financial goals.^1–3 Equitable, person-centered contraceptive access can promote reproductive autonomy and advance sexual and reproductive health equity so that people across the range of age, gender, race, and other intersectional identities have what they need to attain their highest level of health.^4,5 Yet, many people in the United States face barriers to accessing contraception, including cost, insurance gaps, and institutional barriers.⁵ Discrimination and structural racism, both within and outside of the health care system, intensify these barriers for people of color, people living in poverty, people with disabilities, people who are immigrants, and others with marginalized identities.

STATEWIDE CONTRACEPTIVE ACCESS INITIATIVES

There is growing evidence that statewide contraceptive access initiatives can expand contraceptive access, advance the provision of person-centered care, and improve health outcomes.^6–8 Statewide contraceptive access initiatives are population-level approaches, typically serving large geographic areas within a state, that require collaboration across multisectoral partners such as state health departments, public and private payors, health and community systems of care, and community and advocacy groups. In these initiatives, a coalition of organizations undertakes coordinated efforts to expand contraceptive access, including providing training and capacity building within health care organizations; mobilizing for policy change to increase contraceptive access, affordability, and availability; and removing structural barriers to enhanced access. Since 2007, at least 28 states and local jurisdictions have implemented contraceptive access initiatives.

The reproductive health field has evolved considerably over the past 20 years, particularly in the increased adoption of approaches informed by reproductive justice and person-centered care frameworks. This evolution is reflected in the history of contraceptive access initiatives. Early interest in the potential of these initiatives was sparked by evidence generated by the Contraceptive CHOICE Project, implemented in St. Louis, Missouri, in 2006; this project documented the dramatic impact that long-acting reversible contraceptive (LARC) use can have on unintended pregnancies when barriers, including cost, are removed.⁹ In response, state and funder interest prompted the implementation of several contraceptive access initiatives focused on addressing barriers specific to LARC access, including cost and logistical barriers (e.g., need for provider training on insertion and removal, lack of availability of devices in clinics and hospitals).

However, LARC-first or LARC-centered approaches, such as the tiered effectiveness contraceptive counseling model, ignored the many factors beyond method effectiveness that may shape a person’s contraceptive preferences and decision making across the life span, as well as the long history of reproductive coercion in the United States.^10,11 Years of advocacy by reproductive justice leaders made clear that traditional “family planning” programs rest on culturally problematic assumptions regarding parenthood, pregnancy intention, and personal decision making. This activism was driven by the reproductive justice theoretical framework, developed by women of color, which asserts that it is a human right to maintain personal bodily autonomy, have or not have children, and parent in safe and sustainable communities.^12,13

As a result, many contraceptive access initiatives shifted from LARC-first or LARC-centered approaches to focus on expanding access to a broad range of methods in which counseling approaches center individuals’ preferences and promote reproductive autonomy.¹⁴ This shift was accompanied by an increased focus on health and social outcomes that better represent the preference-sensitive nature of contraceptive care, such as access to care and individuals’ reports that care was person centered, respectful, and noncoercive. Many initiatives are currently undergoing robust evaluations to document these outcomes.

SCALING UP EVIDENCE-BASED PRACTICES

To more concretely understand, support, and elevate efforts to build a more current and comprehensive evidence base for contraceptive access initiatives, the Coalition to Expand Contraceptive Access and the Association of State and Territorial Health Officials virtually convened representatives of seven contraceptive access initiatives in fall 2020 to explore the health and social effects of contraceptive access initiatives, outline program intervention and evaluation elements commonly applied across initiatives, consider opportunities to share successes and lessons learned, and support scaling of similar efforts by disseminating best practices.

One vehicle to disseminate best practices for population health interventions is the Centers for Disease Control and Prevention’s Guide to Community Preventive Services (Community Guide), a collection of evidence-based findings from the Community Preventive Services Task Force. By detailing the feasibility of large-scale contraceptive access initiatives and their impact on sexual and reproductive health and well-being, a Community Guide recommendation on contraceptive access initiatives has the potential to expand access to contraceptive care, increase implementation of best practices, encourage cross-agency coordination, and inform funding proposals to support scaling of similar efforts. To that end, this article, and the collection of articles in this special issue, aims to contribute to and strengthen the body of evidence on the effects of contraceptive access interventions as a means of informing a future Community Guide recommendation.

ESTABLISHING A SHARED UNDERSTANDING

Here we describe intervention and evaluation components commonly implemented across contraceptive access initiatives and outline the potential benefits of an evidence-based population-level programmatic guideline for such initiatives.

Intervention Components for Contraceptive Initiatives

Eight multilevel core intervention components are commonly implemented across contraceptive access initiatives (Table 1). These intervention components include training or continuing education and ongoing technical assistance at the health care provider level; provision of low- or no-cost contraception, grants for contraceptive equipment or supplies, and quality improvement and monitoring at the health care organization level; public awareness campaigns and stakeholder engagement at the community level; and legislation or other policy changes at the public policy level. Implementation of these intervention components is interrelated and represents a theory-based, systems change approach wherein multiple interventions are implemented across levels (e.g., health care organization level, community level) to maximize effects across diverse and often fragmented systems of care in each state.

TABLE 1—

Core Intervention Components for Statewide Contraceptive Access Initiatives

Intervention Component	Description
Health care provider level
Training/continuing education	Training for clinicians, support staff, and administrative staff through various modalities (e.g., small-group in-person training, one-on-one proctoring, virtual Webinar series) on topics including family planning; medical management of contraception; hands-on clinical skills (e.g., LARC insertion and removal); billing, coding, and reimbursement; and preventing coercion and bias
Ongoing technical assistance	Ongoing, targeted technical assistance to clinicians, support staff, and administrative staff through various modalities (e.g., coaching calls, in-clinic training specialists) on topics including hands-on clinical skills; purchasing, stocking, and billing for contraceptives; patient education materials; contraceptive access policies/procedures; contraceptive workflow; and data collection and reporting
Health care organization level
Provision of low- or no-cost contraception	Direct funding or stocking for participating health centers across delivery settings (e.g., Title X clinics, Federally Qualified Health Centers, school-based health centers, hospitals for immediate postpartum contraception, abortion providers for immediate postabortion contraceptiona) to offer FDA-approved contraceptive methods and services to eligible individuals at low or no cost without per-client caps on use of contraceptive services and devices
Grants for equipment/supplies	Direct funding to participating health centers to purchase contraceptive supplies and equipment, other clinic supplies (e.g., examination tables, technology for patient education), and supplies for personnel
Quality improvement, data, monitoring, and evaluation	Continuous quality improvement and feedback to quickly identify implementation barriers and potential strategies to address barriers; ongoing measurement of aggregate, deidentified data on use of various contraceptives; provision of contraception services or person-centered counseling; and knowledge, skills, attitudes, or beliefs about contraception among providers
Community level
Public awareness campaign	Digital media and marketing campaigns to increase awareness about the availability of reproductive health services and provide information and resources on reproductive health topics
Stakeholder engagement	Engagement in multistakeholder partnerships with public and private entities for effective implementation
Public policy level
Legislation or other public policy change	Championing of enactment and implementation of legislation and public policy to support contraceptive access, including overall public and private insurance coverage for contraception, such as LARC coverage and reimbursement and multiple months of dispensing; expanded ability of providers (e.g., pharmacists, advanced practice clinicians) to prescribe and dispense contraception; ensured payment parity for providers; and over-the-counter contraception without a prescription

Note. LARC = long-acting reversible contraceptive; FDA = Food and Drug Administration.

^aTwo of the seven contraceptive access initiatives that participated in the virtual meeting series included postabortion contraception access in their programs.

An expanded focus on access to a broad range of contraceptive methods and more person-centered approaches has often led contraceptive access initiative implementers and evaluators to modify program components. For example, some initiatives have integrated new strategies focused on principles of equity and justice, including acknowledging historical and contemporary racism, reproductive coercion, and how systems of care promote harmful program planning and implementation practices, particularly in communities of color; integrating training on bias and coercion for health care providers and staff; and convening community advisory boards in which members are empowered to influence program direction and compensated for their time.

Outcomes Examined Across Contraceptive Initiatives

Evaluations of contraceptive access initiatives typically involve assessments of various practice, policy, individual, community, health, and social outcomes, as depicted in the conceptual framework for statewide contraceptive access initiatives shown in Figure A (available as a supplement to the online version of this article at http://www.ajph.org). Practice and policy outcomes are relevant to care delivery and clinical practice, as well as institutional and public policy changes that may have an impact on contraceptive care. These outcomes include knowledge, skills, attitudes, and beliefs about contraception among providers; provision of person-centered counseling and contraceptive services; and health system and clinic-level policies and procedures that support access to widespread person-centered contraceptive services (e.g., enabling stocking of a broad range of contraceptive methods at the clinical site).

Individual and community outcomes are affected by practice and policy factors and include individuals’ reports that contraceptive care was provided in a person-centered manner, reproductive health service use, and contraceptive use that reflects individuals’ needs and preferences. Effects on unintended pregnancy, births, and abortions are among the health and social outcomes of interest in some contraceptive access initiatives. Other outcomes of interest include maternal and infant health-related outcomes and reproductive well-being, defined as having the necessary access to information, services, and support to make decisions related to sexuality and reproduction and being empowered to act on those decisions.¹⁵

PUBLIC HEALTH IMPLICATIONS

Contraceptive access initiatives have the potential to greatly enhance the accessibility of this essential preventive service. Public funding plays a critical role in ensuring equitable access to contraception and other reproductive health services, but systems of care are often siloed and fragmented, requiring clinical and policy innovation and meaningful resource investments to facilitate expanded access. Contraceptive access initiatives have the potential to foster collaboration across a variety of stakeholders, provide needed training and capacity building within and across health care systems, and remove structural barriers to enhanced access through community-level interventions and public policy change.

Equitable, Person-Centered Contraceptive Care

Since the early interest in and implementation of these projects, many contraceptive access initiatives have expanded beyond LARC-first or LARC-centered approaches to focus on enhancing access to a broad range of contraceptive options and counseling approaches that center individuals’ preferences, priorities, and autonomy. This focus on promoting person-centeredness in contraceptive care and advancing sexual and reproductive health equity presents an opportunity for these initiatives to examine and address broader issues in the field such as the influence of provider and partner coercion and bias on contraceptive choice; the association between person-centered care and contraceptive outcomes in diverse communities; racial inequities and rural gaps in contraceptive access; linkages to comprehensive sexual and reproductive health services, including sexual health services, fertility care, and pregnancy-related care (e.g., prenatal and postpartum care); and inequities in pregnancy and maternal health outcomes.

This equity-focused approach offers the ability to evaluate the extent to which contraceptive access initiatives focused on person-centeredness and equity lead to increased access, use, satisfaction, and quality of care. It also presents an opportunity to define, develop, and test measures to assess more holistic aspects of reproductive health such as reproductive well-being. A growing body of literature suggests that these alternative conceptualizations of reproductive health and well-being could balance, or even replace, the conventional population health measure of unintended pregnancy, a measure that has long been regarded as a proxy for women achieving their desired reproductive outcomes but has been increasingly called into question with respect to its validity.^16–19 The framework in Figure A reflects health and social outcomes assessed in some contraceptive access initiatives (e.g., effects on unintended pregnancy) as well as opportunities for integrating alternative person-centered measures in the future (e.g., reproductive well-being).

Impact of a Community Guide Recommendation

Experts in the field have identified the development and dissemination of evidence-based population health guidelines related to expanding contraceptive access, such as the Community Guide, as a priority.²⁰ However, the extent to which the Community Guide currently addresses contraceptive access is limited primarily to examining contraceptive use as an indicator of an intervention’s success.

Currently, contraception is mentioned in the Community Guide in six instances; five interventions focus on educational programs for adolescents, with contraceptive uptake assessed as a measure of program effectiveness, and the sixth focuses on how school-based health centers can improve health equity in low-income communities. Although the school-based health center recommendation has a broader potential reach than the educational programs, it is still applicable only to the specific infrastructure around adolescent health care delivery. A Community Guide recommendation on contraceptive access initiatives would advance coordinated, population-based approaches to expand contraceptive access beyond individual-level educational interventions and promote evidence-based, multilevel systems change interventions with applicability to a broader group of individuals and communities.

Therefore, this special issue and the collection of articles within it set the stage for future consideration by the Community Guide. Consistent with the Community Guide’s intent, statewide contraceptive access initiatives promote health within the realm of sexual and reproductive health. A Community Guide recommendation would confer great benefit to both research on and the practice of population health improvement and could help ensure that future contraceptive access initiatives include shared, evidence-based practices.

With the scientific evidence still accumulating, we hope that this special issue will encourage funders to support the evaluation of contraceptive access initiatives so that the body of evidence is robust, encourage program implementers to incorporate the core intervention components described here into their states’ unique contexts to improve alignment across projects nationwide, and encourage program evaluators to align their evaluation strategies with those presented here and the accompanying conceptual framework so that evidence can be compared across states. These steps will help advance progress toward the goal of ensuring that all people have meaningful access to person-centered contraceptive care.