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Unintended Pregnancy and Long-Acting Reversible Contraceptives

Written by Dr. Joshua Mueller and Dr. Jill Barnas
Published on June 29, 2021
Research Highlights

In contrast to oral contraceptives or sterilization, long-acting reversible contraceptives (LARCs) are a form of birth control that prevent pregnancy for long durations after application (months to years), but whose use can be discontinued at any point without affecting fertility.

  • An estimated 45% of pregnancies in the United States are unintended, with higher rates for adolescents, low-income women, and women without insurance. Unintended pregnancies have been tied to negative social, economic, and health consequences for parents and children.
  • State-level policies that increase access to LARCs have been shown to increase LARC use and decrease teen birth rates, which are often a proxy for unintended pregnancies.
  • Programs in St. Louis and Colorado have also demonstrated that providing access to LARCs can reduce unintended pregnancy rates, teen birth rates, and abortion rates.

Executive Summary

In contrast to oral contraceptives or sterilization, long-acting reversible contraceptives (LARCs) are a form of birth control that prevent pregnancy for long durations after application (months to years), but whose use can be discontinued at any point without affecting fertility. LARCs include intrauterine devices (IUDs), subdermal implants, and injectable contraceptives. LARC methods are the most effective forms of reversible contraception, with a failure rate less than 1%. Several programs and policies have demonstrated that increasing the availability of LARCs decreases the number of unintended pregnancies and abortions, and saves costs associated with unintended pregnancy.

Limitations

  • Only a few long-term studies of negative outcomes for children conceived unintentionally have been performed in the United States. The results from these studies are observational, meaning that it is difficult to confidently assign the cause of these outcomes to unintentional pregnancy alone.
  • There is currently a lack of data on LARC use in Missouri, so it is difficult to assess how the state compares in terms of access and uptake.

Research Background

Unintended pregnancies

In the United States, approximately half of all pregnancies are unintended, meaning that the mother is either not ready to have a child at the time of pregnancy, or does not want to have a child at all. For adolescents, an estimated 85% of pregnancies are unintended. Low-income women and those without insurance are as much as five times more likely to experience unintended pregnancies than women with household incomes over 200% of the federal poverty level.1 Approximately half of unintended pregnancies result from omission of contraception, and the other half result from inconsistent/incorrect use or contraceptive failure.2

Unintended pregnancies are associated with negative social, economic, and health consequences for parents and children. Women who experience unintended pregnancies are more likely to have mental health problems, experience physical abuse, and seek abortions.3 Specifically, a 2012 study estimated that 43% of unintended pregnancies in the United States end in abortion.2

Correlational studies also suggest that children born from unintended pregnancies are at increased risk of negative mental health outcomes, more likely to drop out of high school, and more likely to be convicted of a crime.3 Overall, unintended pregnancies are associated with an estimated $21B in costs to the federal government each year through programs such as Medicaid, Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).1

Access to LARCs

The pregnancy rate for women using a LARC method is less than 1%, which is 6–20 times lower than the rate among women using short-acting methods or condoms, indicating that LARCs are an effective birth control method for those seeking to avoid pregnancy.4 The Department of Health and Human Services required that, under the Affordable Care Act, most private health insurance plans cover the full range of FDA-approved contraceptive methods without patient cost-sharing. As a result, the proportion of claims with $0 cost-sharing for IUDs, rose from 36.6% in 2010 to 87.6% in 2013.5

In Missouri, the state Medicaid program (MO HealthNet) provides family planning services, including LARCs, through the Uninsured Women’s Health Services Program. Women in households making less than 201% of the federal poverty level are eligible for this program. The federal government reimburses the state for 90% of the cost of family planning services and supplies, which is higher than the standard Medicaid reimbursement rate.

In addition, Title X, a federal program that provides funds to approximately 4,000 clinics across the United States, supports the delivery of family planning services to low-income individuals. Section 330 Grants also support Federally Qualified Health Centers (FQHCs), which provide primary care services, including some family planning care, to poor and underserved patients.6

Several state-level policies have also been associated with increased LARC access and uptake. For example, when South Carolina implemented a separate Medicaid payment for immediate postpartum LARC (i.e., independent of the billing for the delivery), the percentage of birthing mothers who received a postpartum LARC increased sevenfold (from less than 0.5% to about 3.5%) over 3 years.4 Missouri currently has an identical billing rule in effect.

In addition, Medicaid expansion has been associated with an increase in LARC use by 1.2 percentage points among women at risk of unintended pregnancy in states that expanded Medicaid compared with nonexpansion states. Among adolescents, the association was larger, at about 1.8 percentage points over three years.7

Finally, Medicaid waivers that increase income limits for eligibility have been shown to increase the number of women receiving Medicaid-funded family planning services and reduce overall births to non-teens by about 2% and to teens by over 4%. Estimates from states implementing such waivers indicate that each unintended birth avoided through expansion of Medicaid eligibility cost approximately $7,000 in 2007.8

Benefits of increased LARC access

Several programs have been implemented across the country to increase access to LARCs, with the intention of decreasing unintended pregnancies and abortions. One such pilot program, the Contraceptive CHOICE Project, was launched in St. Louis in 2007. This project enrolled around 10,000 adolescents and women at risk for unintended pregnancy into a study of the effects of reversible contraceptive methods. Participants who desired but did not yet have reliable access to contraceptives were recruited from the two abortion facilities in the St. Louis region and through provider referral, advertisements, and word of mouth. Participants were counselled about the requirements and effectiveness of reversible contraceptive methods, and received the reversible contraceptive method of their choice at no cost. 75% of participants chose a LARC method.2

This study reported a significant reduction in abortion rates among participants from 2007 to 2011. Abortion rates of the CHOICE participants (4.4–7.5 per 1,000 women) were less than half the regional rate (13.4–17 per 1,000) and national rate (19.6 per 1,000). Additionally, the teenage birth rate within the CHOICE participants was 6.3 per 1,000, compared to the U.S. rate of 34.1 per 1,000. Finally, the percentage of repeat abortions in the St. Louis region decreased from 48% to 44% over this time frame. In contrast, the repeat abortion rate increased in Kansas City and nonmetropolitan Missouri, which did not operate similar programs over the same time period. The study authors estimated that one abortion could be prevented for each approximately 100 women and teenagers provided with LARC counselling and access.2

In 2008, the Colorado Department of Public Health and Environment launched the Colorado Family Planning Initiative (CFPI), which provided training, operational support, and low- or no- cost LARCs to low-income women in the state. By 2015, the program provided over 36,000 LARCs. As a result, an estimated 2,500-3,300 unintended pregnancies for 15–24 year olds were avoided between 2010 and 2014. Researchers estimate that Colorado saved $66–69M in entitlement program costs (Medicaid, TANF, SNAP, and WIC) related to those births.9

Another study in Indiana found that same-day LARC placement was associated with lower overall costs ($2,016 per patient per year) compared with LARC placement at a follow-up visit after a consultation ($4,133 per patient per year). These savings to the Indiana Medicaid program resulted mostly from avoiding costs associated with unintended pregnancy, such as delivery or, in some cases, abortions. Compared with follow-up placement, same-day LARC was associated with an unintended pregnancy rate of 14% vs 48% and an abortion rate of 4% vs 14%.1

References

  1. Wilkinson, T.A., Downs, S.M., Edmonds, B.T. (2019) Cost Minimization Analysis of Same-Day Long-Acting Reversible Contraception for Adolescents. JAMA Netw. Open, 2(9): e1911063.
  2. Peipert, J.F., Madden, T., Allsworth, J.E., Secura, G.M. (2012) Preventing Unintended Pregnancies by Providing No-Cost Contraception. Obstet. Gynecol., 120(6): 1291-1297.
  3. Thomas, A., Monea, E. (2011) The High Cost of Unintended Pregnancy. Center on Children and Famlies at Brookings, Brief #45. https://www.brookings.edu/wp- content/uploads/2016/06/07_unintended_pregnancy_thomas_monea.pdf
  4. Steenland, M.W., Pace, L.E., Sinaiko, A.D., Cohen, J.L. (2021) Medicaid Payments For Immediate Postpartum Long-Acting Reversible Contraception: Evidence From South Carolina. Health Affairs, 40(2): 334-342.
  5. Pace, L.E., Dusetzina, S.B., Keating, N.L. (2016) Early impact of the Affordable Care Act on uptake of long- acting reversible contraceptive methods. Med. Care, 54(9): 811-817.
  6. Ranji, U., Salganicoff, A., Sobel, L., Gomez, I. (2019) Financing Family Planning Services for Low-income Women: The Role of Public Programs. Henry J. Kaiser Family Foundation Issue Brief. https://www.kff.org/wp-content/uploads/2019/10/Issue-Brief-Financing-Family-Planning-Services-for- Low-income-Women-1.pdf
  7. Darney, B.G., Jacob, L.R., Hoopes, M. (2020) Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers. JAMA Netw. Open, 3(6): e206874.
  8. Kearney, M.S., Levine, P.B. (2007) Subsidized Contraception, Fertility, and Sexual Behavior. NBER Working Paper Series, #13045.
  9. Colorado Department of Public Health and Environment, Taking the Unintended Out of Pregnancy: Colorado’s Success with Long-Acting Reversible Contraception, January 2017. https://www.colorado.gov/pacific/sites/default/files/PSD_TitleX3_CFPI-Report.pdf
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