Improving Access to Contraception in Delaware

The Problem: Unplanned Pregnancy

Over a half century after the United States Food and Drug Administration first approved the birth control pill for contraceptive use, nearly half of all pregnancies in the United States are unplanned, resulting in 1.5 million unplanned births per year.¹ The children who result from these unplanned pregnancies frequently have poorer health and economic outcomes. Unplanned babies suffer from higher rates of deferred prenatal care and are frequently born at lower gestational ages and birth weights, conditions which have lifelong negative consequences.² However, unplanned pregnancy is more than a health issue. Young parenthood (which is often unintended) contributes to more than 25 percent of all high school dropouts—and more than one-third of all female dropouts.³ Put simply, in the United States today, unplanned pregnancy can contribute to intergenerational poverty and health and economic inequality.

The burden of unplanned pregnancy is distributed unevenly across the economic spectrum. Low-income women are five times more likely than women with incomes above 200 percent of the federal poverty level to experience unplanned pregnancy.⁴

Of the 38 million women in need of contraceptive care in the United States in 2010, 20 million were in need of publicly funded contraceptive services. These women account for 75 percent of all unplanned pregnancies in the United States.⁵

In 2010, Delaware’s unplanned pregnancy rate was the highest in the nation with 62 unplanned pregnancies for every 1,000 women aged 15–44. That same year, 57 percent of Delaware’s 19,300 pregnancies were unplanned, and 40 percent of the 11,400 resulting births were unplanned.⁶ The total, annual healthcare related public cost of unplanned pregnancies in the state was approximately $94 million, of which state funds paid $36 million.⁶ Research shows that unplanned pregnancies are expensive and cost women, families, government, and society significant resources.⁷

The Opportunity: Long-Acting Reversible Contraception

There are many reasons for the uneven distribution of unplanned pregnancy in the United States, but a major one is access to some of the most effective forms of contraception: long-acting reversible contraception (LARC) such as an intrauterine device (IUD) or implants. In the United States, many women cannot easily access LARCs because health centers either do not offer LARC methods or impose barriers that make it very difficult to obtain them. This state of affairs persists despite the fact that LARCs are endorsed by The American College of Obstetricians and Gynecologists, American Academy of Pediatrics, and Centers for Disease Control as a safe and effective “first-line” choice.^8–10 Moreover, IUDs and the implant are available free or without co-pay to the vast majority of low-income women in the United States, thanks to state-by-state contraceptive coverage laws and public family planning funding provided through the Title X program and Medicaid.¹¹ Despite the many benefits of LARCs and their relative affordability, a recent study found that one-third of clinics providing publicly funded family planning services—primarily to clients under 250 percent of the federal poverty level—offer no LARC methods, and 70 percent of primary care clinics do not offer the implant.¹²

Many health centers and the clinical providers and staff who work in them do not have the systems, expertise, or knowledge to offer their patients the full range of contraceptive methods, including LARC. Often, providers do not have the training to provide IUDs and the implant.

Misinformation and poor patient counseling mean that many women who are eligible for LARCs are not informed of the option. Even when patients can receive LARCs, many health centers require that their patients make multiple visits to get them, adding barriers to care and longer waits. Billing and coding problems make it difficult for health centers to stock the expensive devices. Cost fears also prohibit many patients from seeking LARCs.

The potential benefits of greater LARC access are even more apparent when you consider that more than 40 percent of unplanned pregnancies occur among women who were using contraception. However, these women are not using the form of contraception that works well for them.¹ Poor compliance is particularly an issue with the hormonal birth control pill. On average, a woman’s chance of getting pregnant over ten years while on the pill is 61 percent, mostly due to poor compliance.¹³ There is strong evidence that when financial barriers to LARC access are removed and women are counseled well about their contraceptive options, many more will choose— and be more satisfied with—a long-acting reversible form of contraception.¹⁴

Upstream’s Solution

Upstream USA is a national, fast-growing nonprofit that is working to expand economic opportunity and mobility by reducing unplanned pregnancy in the United States. Upstream’s approach takes three critical steps to help reduce unplanned pregnancies:

1. Enable health centers to ask all women of reproductive age as a routine part of primary care if they want to get pregnant in the next year;

2. Enable health centers to provide women with single-visit access to the full range of contraceptive methods, including LARC, so women can freely choose the best method for them; and

3. Create consumer demand for contraception by developing public awareness campaigns to educate women about their options.

Recent, rigorous evaluations of comparable statewide and national initiatives demonstrate the effectiveness of this approach in reducing unplanned pregnancies.^14,15

Upstream partners with states, including Delaware, to deliver training, technical assistance, and quality improvement to health centers so that they can offer their patients the full range of contraceptive methods the same day they are requested. Upstream’s model is a comprehensive, customized, whole health center approach to creating system-level, clinic-level, and provider-level changes. Upstream’s intervention includes an initial diagnostic visit to assess each health center’s needs and barriers regarding contraceptive access, one- to-two days of in-person training that incorporates adult learning techniques, and approximately twelve months of intensive technical assistance and quality improvement. Technical assistance is tailored to help each health center overcome the specific barriers that prevent them from providing women with same-day access to the full range of contraception, including provider knowledge, clinic work flow, stocking, billing, coding, and consumer awareness. By training and equipping health centers to embed these practices in their workflow and to access existing public and private funding streams for contraception, Upstream’s model ensures these changes will be sustained long after its training is complete and will benefit increasing numbers of women and families for years to come.

Delaware CAN

In 2015, Upstream launched Delaware Contraceptive Access Now (Delaware CAN), a public-private partnership with the Delaware Division of Public Health with the support of then-Governor Jack Markell. The goal of Delaware CAN is to reduce the rate of unplanned pregnancy in Delaware. The project plans to demonstrate that dramatic improvements in contraceptive access, counseling, and care can significantly reduce unplanned pregnancies and improve birth outcomes. In addition, Upstream projects that a reduction in unplanned pregnancies will save the state millions of dollars in pregnancy-related health care and other public costs. Upstream is creating a healthcare infrastructure that empowers all women in Delaware, regardless of insurance status, with convenient, same- day access to the full range of contraceptive methods, including the most effective, IUDs and the implant.

Upstream provides comprehensive training and technical support to the vast majority of public and private healthcare providers and a broad set of social service agencies in the state. Providers receive training on the insertion and removal of LARC; staff receive training on workflow support and assistance with contraceptive billing and stocking; and the entire team learns how to counsel patients effectively about all forms of contraception. As of December 31, 2017, Upstream has provided 99 trainings to 547 clinicians and 1589 support staff at 164 sites across the state of Delaware, including 85 public and private healthcare providers and a broad set of 79 social service providers. These sites represent 41 agencies which annually serve nearly 125,000 of Delaware’s approximately 190,000 women of reproductive age, and this number continues to grow as sites take on new patients and clients over time.¹⁶

Additionally, offering contraceptive care in the hospital postpartum setting is a vital opportunity to help women prevent unplanned pregnancies and provide women support for their goals of healthy birth spacing. Upstream has collaborated with Delaware Medicaid and Medical Assistance and health centers to ensure that policies and practices are conducive to providing women the full range of contraception the same day as requested including Immediate Postpartum (IPP) LARC. This collaboration resulted in rule changes establishing a separate reimbursement fee for IPP LARC devices in the hospital setting and in the outpatient setting at federally qualified health centers, removing a financial barrier that had kept many public providers from offering LARCs.

Currently, four out of five birthing hospital systems in Delaware, which account for 86 percent of births in the state, now provide IPP LARC.

In addition to improving access through training and technical support, Upstream is committed to ensuring that all women in Delaware are aware of the accessibility of effective contraception and know where to go to receive best-in-class contraceptive care. In May 2017, Upstream launched a consumer campaign, Be Your Own Baby, after over a year of development with direct input from Delaware women. The campaign helps Delaware women overcome barriers to contraception and drives demand to Upstream-trained health centers. It supports Upstream’s model by helping patients understand they have access to free and convenient contraception and facilitating their ability to schedule an appointment and get to the health center. Response to the campaign among Delaware women has been overwhelmingly positive, and early evidence suggests the campaign is inspiring women to schedule appointments at Upstream- trained health centers.

Early Evidence of Outcomes

The early evidence of Upstream’s outcomes among Delaware healthcare providers is very promising. Provision of all methods of contraception, including LARC, has begun to increase. Delaware Title X clinics, which include all federally qualified health centers, state-run clinics and Planned Parenthood of Delaware, provide family planning services to low-income individuals and treat a high proportion of women at highest risk of unplanned pregnancy. At Delaware Title X sites, the percentage of women ages 15-44 (excluding those pregnant or seeking pregnancy) who left with any method of contraception rose from 52 percent in 2014 to 65 percent in 2016, and the percentage who received a Title X service and left with a LARC method rose from 6 percent in 2014 to 15 percent in 2016 (see Figure 1).

Figure 1.

Delaware Title X Sites: LARC Use at End of Visit

These positive results have been coupled with strong evidence that Delaware women visiting Upstream- trained health centers are making their own decisions about which birth control method is right for them.

Last year, Upstream fielded a patient survey at a representative sample of sites to assess whether Delaware women visiting Upstream-trained health centers are receiving care that effectively empowers them to choose the contraceptive method that is best for them. According to preliminary results, 99 percent of women reported that they chose or made a shared decision with their healthcare provider about their preferred method of contraception, and 98 percent of women reported that they did not feel pressured by someone to use a particular method of birth control at their visit.¹⁷

To assess Delaware CAN’s long-term impact, the University of Maryland, in partnership with the University of Delaware, is conducting an independent evaluation of the intervention. The evaluation includes both a process and impact study and focuses on assessing the initiative’s key outcomes of interest, including contraceptive use, LARC use, Medicaid costs, and unplanned pregnancies resulting in unplanned births.

Though it will be several years before there are any long-term results from Delaware CAN, feedback on Delaware CAN has been resoundingly positive throughout the state.

Conclusion

Given Upstream’s early progress in Delaware and significant demand from healthcare leadership across the United States, Upstream is poised to scale its intervention nationwide and to empower millions of women to plan if and when they want to become pregnant. Upstream has already begun working with stakeholders and funders to launch additional statewide projects and by 2023, Upstream’s goal is to reach health centers that serve 1.6 million women of reproductive age in three states beyond Delaware.