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Long-acting reversible contraception access

Health Factors: Sexual Activity Access to Care
Decision Makers: Local Government State Government Federal Government Grantmakers Healthcare Professionals & Advocates Nonprofit Leaders Public Health Professionals & Advocates
Evidence Rating: Some Evidence
Population Reach: 20-49% of WI's population
Impact on Disparities: Likely to decrease disparities

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Description

Long-acting reversible contraceptives (LARCs) include intrauterine devices (IUDs) and implants that can prevent pregnancy for 3 to 10 years, and can be removed at a woman’s discretion. LARCs are over 99% effective, a higher effectiveness rate than other birth control options (CDC-Contraception). LARCs can be used safely by teens and women regardless of whether they have previously given birth (ACOG-LARC). LARCs can be made accessible through broad-based efforts to decrease patient costs, often by ensuring that LARCs are available at low or no cost through Title X family planning sites and other sources of care, and efforts to support provider training on LARC insertion and removal, and ensuring consistent availability at local clinics. Health care providers can also offer patients comprehensive counseling on the range of birth control options, including LARCs (CDC-Vital Signs 2015).

Expected Beneficial Outcomes

Increased use of contraception
Reduced teen pregnancy
Reduced unintended pregnancy

Evidence of Effectiveness

There is some evidence that increasing access to long-acting reversible contraceptives (LARCs) through efforts such as comprehensive contraceptive counseling and cost reduction increases uptake of LARCs and reduces unintended pregnancies (Broecker 2016, Harper 2015, Biggs 2015, NBER-Lindo 2015, Ricketts 2014, Secura 2014, Peipert 2012). LARCs are recommended as a safe and effective first-line choice of birth control for teens (ACOG-LARC, AAP-Contraception 2014) and women (ACOG-LARC). However, additional evidence is needed to confirm the effects of efforts to increase access to LARCs and determine which intervention components have the greatest effect.

Interventions such as the Contraceptive CHOICE Project in St. Louis and the Colorado Family Planning Initiative that include both comprehensive contraceptive counseling and provision of no-cost or discounted contraception, including LARCs, can increase uptake of LARCs (Birgisson 2015, Ricketts 2014, Goldthwaite 2015) and reduce unintended pregnancy among teens (NBER-Lindo 2015, Ricketts 2014, Secura 2014, Peipert 2012) and adults (Ricketts 2014). An analysis of Colorado’s initiative suggests teen births decline most in the highest poverty areas (NBER-Lindo 2015).

LARC use appears to increase when out of pocket expenses are low (Broecker 2016, Rocca 2016); reducing costs for family planning services for low income women may also increase use of LARCs, as suggested by an evaluation of an Iowa-based initiative (Biggs 2015). Efforts to train providers to deliver broad-based counseling about birth control options and insert IUDs for interested patients appear to increase LARC selection and use, and reduce pregnancy rates among patients who receive counseling at visits likely to be covered by insurance (Harper 2015). For patients whose visits are not likely to be covered by insurance, studies suggest increases in LARC selection but not initiation (Harper 2015, Rocca 2016).  

Adding a social media component such as Facebook to standard contraceptive counseling may increase patients’ knowledge of contraceptives and use of LARCs (Kofinas 2014). Viewing a 3-part contraceptive education video on a tablet computer, however, does not appear to affect LARC use, even with free contraceptives. Similarly, an assessment of an iOS app with contraceptive information demonstrates no effect on LARC use (Cochrane-Lopez 2016).

Lack of knowledge and cost for patients, providers, and the health care system can be barriers to individuals’ LARC use (Lotke 2015). Lack of training among providers and the upfront costs of LARC devices for clinics may be particular challenges in federally qualified health centers (FQHCs) that are small, located in rural areas, or have limited family planning funding (Beeson 2014). Adolescents in all types of communities face additional barriers such as insurance coverage gaps and out-of-pocket expenses, parental consent requirements and confidentiality issues, provider misconceptions about the clinical appropriateness of youth use, and adolescents’ own lack of information and misconceptions about LARCs (Kumar 2016a, Eisenberg 2013, Baldwin 2013).

One study suggests LARC users may be less likely to use condoms than oral contraceptive users, suggesting a need to incorporate messages about condom use to prevent sexually transmitted infections (STIs) in counseling efforts (Steiner 2016).

LARCs are highly cost-effective (Batra 2015, Eisenberg 2013), and more cost-effective than other methods of contraception such as condoms and birth control pills (Blumentahl 2011). 

Implementation

United States

There are various efforts at state, local, and federal levels to increase access to long-acting reversible contraception (LARCs). The CHOICE project in St. Louis (CHOICE) is an example of a local initiative and efforts in Colorado and Iowa reflect partnerships between state governments and private donors (CHOICE, CDPHE-Title X, Biggs 2015). Delaware has also recently launched a public/private partnership called Contraceptive Access Now (DE-CAN).

The federal Affordable Care Act (ACA) reduced or eliminated the cost of long-acting reversible contraceptives for many women (Birgisson 2015, Ricketts 2014, Biggs 2015, Pace 2016, Bearak 2016). However, states can restrict access to LARCs through insurance regulations and Medicaid eligibility requirements (Batra 2015).

Implementation Resources

ACOG-LARC - American Congress of Obstetricians and Gynecologists (ACOG). Long-acting reversible contraception (LARC) program. Accessed on March 15, 2017
AFY-LARC - Young women and long-acting reversible contraception (LARC). Advocates for Youth (AFY). Accessed on March 15, 2017
Russo 2013a* - Russo JA, Miller E, Gold MA. Myths and misconceptions about long-acting reversible contraception (LARC). Journal of Adolescent Health. 2013;52(4 Suppl):S14-S21. Accessed on March 14, 2017

Citations - Description

ACOG-LARC - American Congress of Obstetricians and Gynecologists (ACOG). Long-acting reversible contraception (LARC) program. Accessed on March 15, 2017
CDC-Contraception - Centers for Disease Control and Prevention (CDC). Reproductive Health: Contraception. Accessed on March 14, 2017
CDC-Vital Signs 2015 - Centers for Disease Control and Prevention (CDC). Preventing teen pregnancy: A key role for health care providers. Vital Signs. 2015. Accessed on March 15, 2017

Citations - Evidence

AAP-Contraception 2014* - American Academy of Pediatrics (AAP) Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-e1256. Accessed on March 14, 2017
ACOG-LARC - American Congress of Obstetricians and Gynecologists (ACOG). Long-acting reversible contraception (LARC) program. Accessed on March 15, 2017
Baldwin 2013* - Baldwin MK, Edelman AB. The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: A review. Journal of Adolescent Health. 2013;52(4 Suppl):S47-S53. Accessed on March 14, 2017
Batra 2015* - Batra P, Bird CE. Policy barriers to best practices: The impact of restrictive state regulations on access to long-acting reversible contraceptives. Women’s Health Issues. 2015;25(6):612-615. Accessed on March 14, 2017
Beeson 2014* - Beeson T, Wood S, Bruen B, et al. Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs). Contraception. 2014;89(2):91-96. Accessed on March 14, 2017
Biggs 2015* - Biggs MA, Rocca CH, Brindis CD, Hirsch H, Grossman D. Did increasing use of highly effective contraception contribute to declining abortions in Iowa? Contraception. 2015;91(2):167-173. Accessed on March 14, 2017
Birgisson 2015 - Birgisson NE, Zhao Q, Secura GM, Madden T, Peipert JF. Preventing unintended pregnancy: The Contraceptive CHOICE Project in review. Journal of Women’s Health. 2015;24(5):349-353. Accessed on March 14, 2017
Blumentahl 2011* - Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to prevent unintended pregnancy: Increasing use of long-acting reversible contraception. Human Reproduction Update. 2011;17(1):121-137. Accessed on March 14, 2017
Broecker 2016* - Broecker J, Jurich J, Fuchs R. The relationship between long-acting reversible contraception and insurance coverage: A retrospective analysis. Contraception. 2016;93(3):266-272. Accessed on March 14, 2017
Cochrane-Lopez 2016* - Lopez LM, Grey TW, Chen M, Tolley EE, Stockton LL. Theory-based interventions for contraception (Review). Lopez LM, ed. Cochrane Database of Systematic Reviews. 2016;(11):CD007249. Accessed on March 14, 2017
Eisenberg 2013* - Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. Journal of Adolescent Health. 2013;52(4 Suppl):S59-S63. Accessed on March 14, 2017
Goldthwaite 2015* - Goldthwaite LM, Duca L, Johnson RK, Ostendorf D, Sheeder J. Adverse birth outcomes in Colorado: Assessing the impact of a statewide initiative to prevent unintended pregnancy. American Journal of Public Health. 2015;105(9):e60-e66. Accessed on March 14, 2017
Harper 2015* - Harper CC, Rocca CH, Thompson KM, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: A cluster randomised trial. The Lancet. 2015;386(9993):562-568. Accessed on March 14, 2017
Kofinas 2014* - Kofinas JD, Varrey A, Sapra KJ, et al. Adjunctive social media for more effective contraceptive counseling. Obstetrics & Gynecology. 2014;123(4):763-770. Accessed on March 14, 2017
Kumar 2016a* - Kumar N, Brown JD. Access barriers to long-acting reversible contraceptives for adolescents. Journal of Adolescent Health. 2016;59(3):248-253. Accessed on March 14, 2017
Lotke 2015* - Lotke PS. Increasing use of long-acting reversible contraception to decrease unplanned pregnancy. Obstetrics and Gynecology Clinics of North America. 2015;42(4):557-567. Accessed on March 14, 2017
NBER-Lindo 2015 - Lindo JM, Packham A. How much can expanding access to long-acting reversible contraceptives reduce teen birth rates? National Bureau of Economic Research (NBER). 2015: Working Paper 21275. Accessed on March 14, 2017
Peipert 2012 - Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstetrics & Gynecology. 2012;120(6):1291-1297. Accessed on March 14, 2017
Ricketts 2014* - Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspectives on Sexual and Reproductive Health. 2014;46(3):125-132. Accessed on March 14, 2017
Rocca 2016* - Rocca CH, Thompson KMJ, Goodman S, Westhoff CL, Harper CC. Funding policies and postabortion long-acting reversible contraception: Results from a cluster randomized trial. American Journal of Obstetrics and Gynecology. 2016;214(6):716.e1-716.e8. Accessed on March 14, 2017
Secura 2014* - Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. The New England Journal of Medicine. 2014;371(14):1316-1323. Accessed on March 14, 2017
Steiner 2016* - Steiner RJ, Liddon N, Swartzendruber AL, Rasberry CN, Sales JM. Long-acting reversible contraception and condom use among female US high school students: Implications for sexually transmitted infection prevention. JAMA Pediatrics. 2016;170(5):428-434. Accessed on March 14, 2017

Citations - Implementation

Batra 2015* - Batra P, Bird CE. Policy barriers to best practices: The impact of restrictive state regulations on access to long-acting reversible contraceptives. Women’s Health Issues. 2015;25(6):612-615. Accessed on March 14, 2017
Bearak 2016 - Bearak JM, Finer LB, Jerman J, Kavanaugh ML. Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: An analysis of insurance benefit inquiries. Contraception. 2016;93(2):139-144. Accessed on March 14, 2017
Biggs 2015* - Biggs MA, Rocca CH, Brindis CD, Hirsch H, Grossman D. Did increasing use of highly effective contraception contribute to declining abortions in Iowa? Contraception. 2015;91(2):167-173. Accessed on March 14, 2017
Birgisson 2015 - Birgisson NE, Zhao Q, Secura GM, Madden T, Peipert JF. Preventing unintended pregnancy: The Contraceptive CHOICE Project in review. Journal of Women’s Health. 2015;24(5):349-353. Accessed on March 14, 2017
CDPHE-Title X - Colorado Department of Public Health & Environment (CDPHE). About Colorado Title X Family Planning. Accessed on March 14, 2017
CHOICE - The Contraceptive Choice Project. Washington University School of Medicine in St. Louis. Accessed on March 14, 2017
DE-CAN - Delaware Division of Public Health and Upstream USA. Delaware CAN. Accessed on March 14, 2017
Pace 2016* - Pace LE, Dusetzina SB, Keating NL. Early impact of the Affordable Care Act on uptake of long-acting reversible contraceptive methods. Medical Care. 2016;54(9):811-817. Accessed on March 14, 2017
Ricketts 2014* - Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspectives on Sexual and Reproductive Health. 2014;46(3):125-132. Accessed on March 14, 2017

Page Last Updated

March 14, 2017

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