January 2022: Power Updates Edition
There are plenty of articles, publications, and stories published every month. To help you distinguish fact from fiction, save time in your already busy day, and share news you may not have otherwise seen, here are ten stories from the last month we thought you might find interesting:
In January 2018, The Maryland Contraceptive Equity Act went into effect. The Act aimed to reduce insurance-based barriers to birth control by eliminating most co-pays, lifting IUD and implant pre-authorization requirements, and covering over-the-counter medications such as emergency contraception among other components. Though the survey data analyzed in this paper only had a 13% response rate, after a little over a year, results show that only 51% of providers were aware of the act. More work must be done to ensure that clinicians are aware of this act—and any similar acts passed in other states—to help them change their prescribing practices to better ensure equitable access.
As the US has a relatively high unplanned pregnancy rate compared to other countries, this study looked to better understand the relationship between a person’s insurance status and whether they are using birth control. Findings show that having insurance is associated with using birth control overall (both LARC and non-LARC methods), but that the exact relationship varies based on a person’s race/ethnicity. For example, Black and Latina women with Medicaid were more likely to use any method compared to white women with commercial insurance while Latina women with commercial insurance were more likely to use a LARC than white women also using commercial insurance. These results indicate that there may be an implicit bias on the part of providers influencing them to recommend LARC methods to Black and Latina people at a higher rate their white peers.
LARC methods are highly effective and safe forms of reversible contraception. However, discontinuation of these methods requires a provider, making it important to understand patients’ reasons for discontinuation and the difficulty they may encounter in trying to discontinue. Using data from the 2017-2019 National Survey of Family Growth dataset, the authors identified more than 6,100 female participants, approximately 23% of which reported ever using LARC methods. Of these, 64% intended to discontinue LARC use at some point. Reasons for removal included side effects (30%), LARC expiration (27%), complications (19%), and pregnancy intention (16%).
However, among LARC users, 11% reported difficulty in discontinuing LARC use, most commonly due to complications including their LARC being moved or lodged (68%). But also 6% reported their provider discouraged removal and 4% had providers unable to remove the LARC. Those who identified as non-Hispanic or other, and those who had no religion identified had the highest proportion of LARC removal difficulty. And 17% of publicly insured patients reported difficulty with removal.
This study found that introducing a low-cost IUD option increased the number of women who chose their method across the board. Among self-pay women there was a 3% increase, among those privately insured there was a 7% increase, and those whose family income was great than 200% of the federal poverty level had a nearly 14% increase. While introducing a low-cost option was associated with more self-pay and women with lower incomes accessing IUDs, the authors caution that simply having a low-cost IUD option is not enough as access is still complicated by many other factors including the availability of IUDs and provider training.
Emergency Medicaid offers only restricted access to postpartum care, especially for those who are recent or undocumented immigrants. Oregon recently expanded postpartum coverage to women using Emergency Medicaid. This study found postpartum care attendance and use of birth control postpartum increased around 40% following the policy’s implementation. Specifically, the use of birth control within 60 days of birth increased 33.2%. The success of this policy showcases the importance of expanding Emergency Medicaid benefits as it significantly improves postpartum care and birth control use.
Pregnancy and Birth
Research has shown that preterm birth and low birth weight—which together make up the second leading cause of infant death in the US—are more likely to occur in short interpregnancy intervals, when conception of a subsequent pregnancy occurs less than 18 months after a previous live birth. Since 2012, South Carolina’s Medicaid program reimburses hospitals for immediate LARC placement in the hopes of increasing LARC usage and improving infant mortality rates. Data from 2009-2015 shows that the policy’s implementation was associated with a nearly 6% increase in LARC usage immediately postpartum, but there was no signification difference in preterm birth or low birth weights.
This study investigated whether the type of long-acting reversible contraceptive (LARC) or the timing during which it was placed had any relation to increasing interpregnancy intervals. Using eight years of Medicaid data from Oregon and South Carolina, researchers found that 41% of people had a short interpregnancy interval and that nearly 70% of birthing people had not received any birth control at the six-month postpartum mark. While nearly 93% of people who used a LARC method postpartum did not have it placed immediately postpartum, data shows that both immediate postpartum placement and placement after six weeks both lower the probability of a short interpregnancy interval when compared to short-acting methods, such as the pill.
Unlike in the US where medication abortion using mifepristone is available only with Risk Evaluation and Mitigation Strategy restrictions, in Canada, medication abortion is available via the same type of prescription used for all other medications. Using data for four years before Canada removed restrictions and a little more than two years of data since the change, the authors of this study found that the abortion rate essentially remained stable as did the number of adverse events and complications. However, the proportion of medication abortions grew quickly compared to abortion procedures.
Medication abortion using misoprostol and mifepristone is currently FDA-approved through 70 days’ gestation. While gestational age has traditionally been confirmed in a clinical setting using pelvic ultrasound, increased interest in reducing barriers to abortion care using telehealth has led researchers to examine how accurately patients seeking abortion in the first trimester can assess their own gestational age. In this study, the authors administered a series of surveys designed to estimate gestational age for patients who later had their gestational age assessed by ultrasound. They determined that using four questions, 93% of patients correctly self-identified that they were less than 70 days’ gestation, while less than 2% of participants were incorrectly screened as eligible for medical abortion despite being more than 70 days on ultrasound. The authors suggest that using gestational age screening questions that do not rely solely on a patient’s last menstrual period may be more effective for remote assessment of gestational age.