Long-acting reversible contraception access

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 (NBER-Bailey 2023, Quinlan 2023, NBER-Kelly 2019, Goyal 2017, Lindo 2017, Harper 2015, Biggs 2015, Ricketts 2014). LARCs are recommended as a safe and effective first-line choice of birth control for teens (ACOG-LARC 2017, AAP-Contraception 2014) and women (ACOG-LARC 2017). However, additional evidence is needed to confirm the effects of efforts to increase access to LARCs while maintaining contraceptive choice for all patients, and to determine which intervention components have the greatest effect.

Avoiding coercion. To avoid reproductive coercion, experts recommend programs working to ensure LARC access provide comprehensive counseling on all contraceptive methods, and to all patients, rather than promoting LARC use within specific groups (NWHN 2024, Gomez 2015), as well as ensuring access to LARC removal when individuals choose, without barriers from provider resistance or insurance coverage (Strasser 2017, NWHN 2024). Additionally, vouchers only redeemable for LARCs limit patient choice, so cost coverage should be available for all contraceptive options (NWHN 2024). Adolescents may be subject to greater pressure to use LARCs, or barriers to LARC device removal (Hendrick 2020). Clinicians who provide contraception to adolescents should have overall knowledge about LARCs and their management, as well as issues specific to adolescents related to counseling, initiation, and continuation (Bahar 2020, Hendrick 2020).

Counseling, training, and costs. Overall, counseling, provider training, and cost support, especially in combination, appear to increase LARC use (Phillips-Bell 2023). Interventions that include both comprehensive contraceptive counseling and provision of no cost or discounted contraception, including LARCs, can increase uptake of LARCs (NBER-Kelly 2019, Birgisson 2015, Ricketts 2014, Goldthwaite 2015) and reduce unintended pregnancy among teens (NBER-Kelly 2019, Lindo 2017, Ricketts 2014, Secura 2014, Peipert 2012) and adults (NBER-Kelly 2019, Ricketts 2014); teen births appear to decline the most in counties with the highest rates of poverty (Lindo 2017). LARC use appears to increase when out-of-pocket expenses are low (Snyder 2018a, Broecker 2016, Rocca 2016) or eliminated (Goyal 2017). For example, for patients whose visits are not likely to be covered by insurance, counseling alone increases LARC selection but not initiation (Harper 2015, Rocca 2016); initiation is associated with insurance coverage or ability to afford out-of-pocket costs (Rocca 2016). In general, cost coverage increases access to and use of contraceptives, especially LARCs, among women with lower incomes (NBER-Bailey 2023); increasing funding for family planning services appears to do so as well (Biggs 2015). Studies in multiple states find that cost coverage for LARCs (Biggs 2015), and counseling with cost coverage, appear to reduce abortion rates (Ricketts 2014, Secura 2014, Peipert 2012).

Adolescents and young adults. Educating health care providers about LARCs, as well as adults who work with teens in non-medical community settings, may increase LARC use among high school students (Aligne 2020). On-site availability of LARCs at school-based health centers may increase LARC use among interested adolescents who are sexually active (Badal 2021). A Colorado-based multi-component intervention for pediatric and family practice clinicians, which included both physician education and integrating a LARC toolkit into the electronic health record system, increased LARC placement for adolescents (Arnold Rehring 2019). Interventions delivering contraceptive counseling via motivational interviewing to adolescent mothers also appear to increase LARC use (Stevens 2017, Tomlin 2017). Separating reimbursement for immediate post-partum LARC placement from birth coverage for Medicaid patients may also increase LARC use among adolescents (Steenland 2021a).

Availability. Offering same-day placement of LARCs when women request them at a clinic visit can increase LARC initiation (McColl 2023), as can offering immediate post-partum insertion (Sothornwit 2022); both are recommended by the American College of Obstetricians and Gynecologists (ACOG) (ACOG-642 2015).

Technology. Studies of social media campaigns or contraceptive education videos suggest they may increase interest in the use of IUDs (Vayngortin 2020, Dineley 2018) but may have no impact on LARC uptake (Byker 2019, Cochrane-Lopez 2016), though adding a social media component to contraceptive counseling may increase patients’ knowledge of contraceptives and use of LARCs (Kofinas 2014).

Barriers. 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). Some states’ Medicaid policies do not reimburse for provider insertion fees when women choose immediate postpartum LARC placement, creating a barrier to access (Kroelinger 2019), and Catholic hospitals also may not comply fully with this Medicaid payment policy (Quinlan 2023). Adolescents in all types of communities face these and additional barriers, such as insurance coverage gaps and out-of-pocket expenses, parental consent requirements and confidentiality issues, provider discomfort and misconceptions about the clinical appropriateness of youth use, and adolescents’ own lack of information and misconceptions about LARCs (Linton 2023, Francis 2017, Kumar 2016a, Eisenberg 2013, Baldwin 2013). Some states prohibit providing contraceptives to individuals under 18 without parental consent (Badal 2021). LARCs can be a desirable discreet contraceptive method for individuals experiencing intimate partner violence, which can include reproductive coercion and control (Russo 2013a).

Sexually-transmitted infections (STIs) risk. Experts note that LARC users are less likely to use condoms than those using less effective contraceptives, possibly because there is less need for back up pregnancy protection or because users may be more likely to have consistent partners, and so experts recommend that sexual health education materials and counseling continue to emphasize condom use as effective STI prevention, in combination with access to LARCs (Steiner 2021).

Cost. 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 (Blumenthal 2011).

Initiatives to increase access to long-acting reversible contraceptives (LARCs) are a suggested strategy to decrease persistent disparities in access to LARCs and in unintended pregnancy between people who have lower incomes or are from racialized backgrounds and those who have higher incomes or are white (Linton 2023, Quinlan 2023, Parks 2016). Experts note, however, that unintended pregnancies may not be undesired, and that increased access to LARCs alone will not address the structural factors determining individuals’ contraceptive use (Higgins 2014a).

For women enrolled in Medicaid, offering same-day LARC placement when requested at a clinic visit can increase use of LARCs (McColl 2023). A study in a Vermont clinic illustrates the barriers presented by a two-visit protocol, as women with Medicaid were less likely to have LARCs inserted than women with private insurance (Higgins 2018). Training providers and funding LARC provision at Title X clinics in Colorado appeared to reduce teen birth rates the most in areas with higher rates of poverty (Lindo 2017). Cost coverage can increase use of contraceptives, especially LARCs, among women with lower incomes, such as those seeking Title X services (NBER-Bailey 2023); increasing funding for family planning services for women with low incomes may also increase use of LARCs (Biggs 2015).

Separating reimbursement for immediate postpartum LARC insertion from global maternity payments can increase use of LARCs among women enrolled in Medicaid (Steenland 2021) and for women who are Black (Quinlan 2023). Experts suggest that offering immediate postpartum LARC placement may decrease disparities in access experienced by women who are Black, by reducing barriers around scheduling, transportation, childcare, and Medicaid eligibility time-out. However, women who are Black may experience greater pressure to choose LARCs and implicit bias and coercion remain a problem in clinical settings (Quinlan 2023).

Best practices for implementing the Medicaid payment policy for LARCs include using a reproductive justice framework and patient-centered approach, with comprehensive counseling for patients about all their contraceptive options to ensure the right match for their needs, desires, and goals (Quinlan 2023). Experts also recommend that providers directly acknowledge historic reproductive injustices related to contraceptives, to address patients’ possible concerns and to facilitate openness in the contraceptive choice process (Higgins 2014a).

Individuals have used contraceptive methods for thousands of years (Anderson 2023a). IUDs were invented in the early 1900s and became widely used in the late 1950s, but fell out of favor when, in 1974, one brand of IUD was linked to pelvic inflammatory disease and related deaths. While this IUD was removed from the market and the U.S. Food and Drug Administration (FDA) gained greater authority to approve and ban medical devices in 1976, public distrust of IUDs persisted for decades (Anderson 2023a) and FDA oversight remains less stringent than for pharmaceutical drugs (US FDA-Milestones). Other LARCs (implants and injections) were FDA-approved in the early 1990s (OBOS-History).

Contraceptive development and promotion in the U.S. has included reproductive rights abuses, both in the U.S. and perpetuated by the U.S. abroad (OBOS-History). U.S. state laws in the early 1900s allowed officials to order individuals be sterilized against their will, primarily women who were poor, Black, or Native American; such laws passed in thirty states by 1929 and coincided with global eugenics movements (OBOS-History, Higgins 2014a). As of the 1990s, officials continued to coerce individuals from marginalized or immigrant backgrounds, those with lower incomes, and those who are disabled, into using LARCs, violating their reproductive rights. Multiple states, including North Carolina, Virginia, and California, have established programs to compensate individuals who experienced forced sterilization, such as those in state-run hospitals, institutions, and correctional facilities (OBOS-History, CalVCB-Sterilization).

Laws in the U.S. have historically criminalized activities like mailing contraceptives and abortifacients, created barriers to researching and developing contraceptives (e.g., the birth control pill), and made it illegal for unmarried women to access birth control (OBOS-History). Teen pregnancy rates have been declining in the U.S. since 1991, though rates are still higher than in other high income nations, and racial and geographic disparities persist (CDC-About teen pregnancy). In rural communities, lack of sexual and reproductive health education and services increases risks for adolescent pregnancy (Ott 2020). Unwanted pregnancies could be terminated in all 50 states prior to the 2022 Dobbs v. Jackson Women’s Health Organization Supreme Court decision which made abortion illegal in almost half of U.S. states (Haiman 2023). This change in law, and other increased barriers to abortion, may increase existing disparities in maternal and infant health (KFF-Hill 2022) as more unwanted pregnancies are carried to term (Haiman 2023).

Global initiatives, such as the United Nations’ Sustainable Development Goals, advocate for individuals to access their preferred contraceptive methods as part of their human rights. Such initiatives note the health and other related benefits, such as education and expanded opportunities for women, that come with access to comprehensive sexual and reproductive health services (WHO-SDG 3.7). Additionally, women’s sexual functioning and satisfaction with contraception, including the possibility that contraceptives may enhance sexual experience, continues to be understudied (Higgins 2014a).

• Is reproductive health care available in your community? Are all individuals able to access and afford their preferred contraceptive methods?
• Are local health care providers trained in patient-centered care, and in LARC education, insertion, and removal?
• Does state law allow individuals under 18 to access contraception, or is parental consent required?

As of 2016, long-acting reversible contraception (LARC) use increased to about 17.8% of contraceptive users, with most using IUDs, while short-acting reversible contraception (SARC) use decreased, from 31.8% to 27.7% (Kavanaugh 2020). From 2008 to 2013, inpatient postpartum LARC insertion also increased (Moniz 2017). Using a LARC method is associated with having given birth once or more (parity), while SARC method use is associated with having never given birth (nulliparity) (Kavanaugh 2020).

There are various efforts at local, state, and federal levels to increase access to LARCs. The Contraceptive Choice Center (formerly 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). The Reproductive Health Access Project offers educational materials for clinicians and patients (rhap-Contraception). The Veteran Health Administration provides reproductive health services to women veterans, including comprehensive birth control options (US VA-Reproductive Health).

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). State Medicaid payment policies vary and do not always address all aspects of care (Vela 2018) though most states have published guidance for Medicaid reimbursement for postpartum LARCs (ACOG-Postpartum LARC).

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