Beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care

In the last decade-plus, there has been growing enthusiasm for long-acting reversible contraceptive methods as the solution to unintended pregnancy in the United States. Contraceptive access efforts have primarily focused on addressing provider and policy barriers to long-acting reversible contraception and have promoted long-acting reversible contraception as first-line methods through marketing and tiered-effectiveness counseling. A next generation of contraceptive access efforts has the opportunity to move beyond this siloed focus on long-acting reversible contraception toward a focus on equity and person-centeredness. Here we define a new framework for increasing equitable access to high-quality, person-centered contraceptive care that includes programmatic elements necessary to provide information and services to address the barriers to accessing quality care, organized into a four-part continuum. The continuum is contextualized within structural, systematic, and social factors that influence experience of contraceptive care. We aim to provide a practical framework for researchers, program implementers, and policy makers to develop and evaluate efforts to improve equitable access to and quality of contraceptive care. Initiatives can intentionally be cognizant of broader structural and social factors that will influence their success and the likelihood of negative unintended consequences for marginalized groups and thus deliberately work to design programs that meet all people’s contraceptive needs and support reproductive autonomy. In the last decade-plus, there has been growing enthusiasm for long-acting reversible contraceptive methods as the solution to unintended pregnancy in the United States. Contraceptive access efforts have primarily focused on addressing provider and policy barriers to long-acting reversible contraception and have promoted long-acting reversible contraception as first-line methods through marketing and tiered-effectiveness counseling. A next generation of contraceptive access efforts has the opportunity to move beyond this siloed focus on long-acting reversible contraception toward a focus on equity and person-centeredness. Here we define a new framework for increasing equitable access to high-quality, person-centered contraceptive care that includes programmatic elements necessary to provide information and services to address the barriers to accessing quality care, organized into a four-part continuum. The continuum is contextualized within structural, systematic, and social factors that influence experience of contraceptive care. We aim to provide a practical framework for researchers, program implementers, and policy makers to develop and evaluate efforts to improve equitable access to and quality of contraceptive care. Initiatives can intentionally be cognizant of broader structural and social factors that will influence their success and the likelihood of negative unintended consequences for marginalized groups and thus deliberately work to design programs that meet all people’s contraceptive needs and support reproductive autonomy. THE PROBLEM: Efforts to expand contraceptive access in the United States over the last decade have predominantly focused on long-acting reversible contraceptive methods, with relative neglect of other aspects of contraceptive access and resulting failure to ensure reproductive autonomy. THE SOLUTION: We define a framework that policymakers, program implementers, and researchers can use as a blueprint for considering a broader range of factors influencing equitable access to high-quality, person-centered contraceptive care and identifying potential solutions. THE PROBLEM: Efforts to expand contraceptive access in the United States over the last decade have predominantly focused on long-acting reversible contraceptive methods, with relative neglect of other aspects of contraceptive access and resulting failure to ensure reproductive autonomy. THE SOLUTION: We define a framework that policymakers, program implementers, and researchers can use as a blueprint for considering a broader range of factors influencing equitable access to high-quality, person-centered contraceptive care and identifying potential solutions. Since 2000, when the first hormonal intrauterine device (IUD) was approved in the United States, there has been growing enthusiasm for long-acting reversible contraceptive (LARC) methods (IUDs and implants). Because LARCs are highly effective at preventing pregnancy, increasing their use has become a primary focus of efforts to achieve public health goals related to reducing unintended pregnancy. Efforts to expand contraceptive access have prioritized LARCs and have primarily focused on addressing cost, provider, and policy barriers to their provision. While this work has been, at least in part, motivated by the fact that these barriers have historically made LARCs disproportionately difficult to access, 1Biggs M. A. Rocca C. H. Brindis C. D. Hirsch H. Grossman D. Did increasing use of highly effective contraception contribute to declining abortions in Iowa? . Contraception. 2015; 91: 167-173Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 2Welti K. Manlove J. Unintended pregnancy in Delaware: estimating change after the first two years of intervention to increase contraceptive access. Child Trends. Bethesda, MD. 2018; Google Scholar, 3Secura G. M. Allsworth J. E. Madden T. Mullersman J. L. Peipert J. F. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol. 2010; 203: 115. e1-115. e7Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar, 4Sanders J. N. Myers K. Gawron L. M. Simmons R. G. Turok D. K. Contraceptive method use during the community-wide HER Salt Lake Contraceptive Initiative. Am J Public Health. 2018; 108: 550-556Crossref PubMed Scopus (32) Google Scholar, 5Colorado Department of Public Health and EnvironmentTaking the unintended out of pregnancy: Colorado’s success with long-acting reversible contraception. Denver, CO: Colorado Department of Public Health and Environment, 2017Google Scholar, 6Association of State and Territorial Health OfficialsDelaware addresses high unintended pregnancy rate through a public-private partnership and comprehensive birth control initiative. Arlington, VA. 2016Google Scholar efforts have often gone beyond addressing barriers to promoting LARCs as first-line contraception through marketing campaigns and a tiered-effectiveness counseling model that emphasizes effectiveness as the most important method attribute. 7Sundstrom B. Billings D. Zenger K. E. Keep Calm and LARC On: A theory-based long-acting reversible contraception (LARC) access campaign. J Commun Healthcare. 2016; 9 (160223230855002) Crossref Scopus (11) Google Scholar, 8Sundstrom B. Billings D. Smith E. Ferrara M. Albert B. Suellentrop K. Evaluating the Whoops Proof S. C. campaign: a pair-matched group pretest-posttest quasi-experimental study. Matern Child Health J. 2019; 23: 1036-1047Crossref PubMed Scopus (4) Google Scholar, 9Madden T. Mullersman J. L. Omvig K. J. Secura G. M. Peipert J. F. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception. 2013; 88: 243-249Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 10Committee on Gynecologic Practice Long-Acting Reversible Contraception Working GroupCommittee opinion no. 642: increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2015; 126: e44-e48Crossref PubMed Google Scholar Many have raised concerns over unintended consequences of such a heavy emphasis on LARC promotion for people’s autonomy and trust in the health care system. This is particularly a concern among communities of color, youth, poor people, undocumented immigrants, and incarcerated individuals for whom the experience of being directed, or coerced, into using particular methods is nothing new but rather part of an ongoing legacy of reproductive oppression. 11Gomez A. M. Fuentes L. Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. Perspect Sex Reprod Health. 2014; 46: 171-175Crossref PubMed Scopus (208) Google Scholar, 12Gubrium A. C. Mann E. S. Borrero S. et al. Realizing reproductive health equity needs more than long-acting reversible contraception (LARC). Am J Public Health. 2016; 106: 18-19Crossref PubMed Scopus (106) Google Scholar, 13Sister Song Women of Color and Reproductive Justice Collective and the National Women’s Health NetworkLong-acting reversible contraception: statement of principles Atlanta, GA. 2016Google Scholar Even when providers do not intend to be directive, an emphasis on LARCs in programmatic work or counseling can be experienced as pressure. 14Mann E. S. White A. L. Rogers P. L. Gomez A. M. Patients’ experiences with South Carolina's immediate postpartum long-acting reversible contraception Medicaid policy. Contraception. 2019; 100: 165-171Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 15Gomez A. M. Wapman M. Under (implicit) pressure: young black and Latina women’s perceptions of contraceptive care. Contraception. 2017; 96: 221-226Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar Furthermore, promoting LARCs as the ideal methods (in counseling or marketing), and assuming that barriers to access are the only reason people do not use them, runs the risk of steering people away from methods that might be most effective for them and perpetuating understandable distrust in family-planning providers and programs. Over the last several years, there has been increasing recognition that, to support patient autonomy, efforts to expand contraceptive access must focus on making all methods accessible. There is also a need to recognize that meeting individuals’ contraceptive needs cannot be limited to ensuring financial and same-day access to contraception. To meaningfully support reproductive autonomy with contraceptive services, it is imperative to also address the range of factors that influence whether individuals have the information and support needed to understand their bodies and seek care, whether they receive respectful care, and whether they are able to effectively use contraception when desired. 1. A person-centered framework for high-quality, equitable contraceptive care This growing recognition of the need to move beyond a siloed focus on LARCs and financial barriers provides an opportunity for a next generation of contraceptive access efforts to do more. Such work can build on past programmatic and policy successes related to LARC provision and expand to addressing a broader range of barriers people face in and out of the health care system. To help guide this next generation, we have defined a framework grounded in principles of person-centeredness and health equity as well as a recognition of the influence of structural and social contexts. Patient-centeredness, as defined by the Institute of Medicine, refers to “providing care that is respectful of, and responsive to, individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. ”16Institute of Medicine Committee on Quality of Health Care in AmericaCrossing the quality chasm: a new health system for the 21st century. National Academies Press (National Academy of Sciences), Washington (DC) 2001Google Scholar Grounding contraceptive access initiatives in the principle of person-centeredness ∗ (We use the term person-centered rather than patient-centered in recognition of the factors outside the health care system that influence whether individuals’ contraceptive needs are met. We recognize that there is also movement toward use of a frame of person-led health care and welcome further elaboration of this frame to deepen accountability of the health care system for prioritizing patient experience and autonomy. ) ∗ (We use the term person-centered rather than patient-centered in recognition of the factors outside the health care system that influence whether individuals’ contraceptive needs are met. We recognize that there is also movement toward use of a frame of person-led health care and welcome further elaboration of this frame to deepen accountability of the health care system for prioritizing patient experience and autonomy. ) inherently leads to prioritization of individuals’ well-being and positive experiences with care, rather than a more narrow focus on preventing unintended pregnancy at the potential expense of people’s autonomy. 17Potter J. E. Stevenson A. J. Coleman-Minahan K. et al. Challenging unintended pregnancy as an indicator of reproductive autonomy. Contraception. 2019; 100: 1-4Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Health equity refers to the goal that everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential. 18World Health OrganizationHealth Equity. 2019. https: //www. who. int/topics/healthₑquity/en/Date accessed: August 15, 2019Google Scholar An equity frame, including a focus on actively countering white supremacy and racism, is critical, given our long societal legacy of favoring the reproduction of affluent, able-bodied whites over other groups, a phenomenon termed stratified reproduction. 19Colen S. Like a mother to them: stratified reproduction and West Indian childcare workers and employers in New York. in: Ginsburg F. R. Conceiving the new world order: the global politics of reproduction. University of California Press, Berkeley, CA1995: 78-102Google Scholar, 20Harris L. H. Wolfe T. Stratified reproduction, family planning care and the double edge of history. Curr Opin Obstet Gynecol. 2014; 26: 539-544Crossref PubMed Scopus (60) Google Scholar Our country has a long history of systematically attempting to control the reproductive lives of women of color, particularly black women, and limit or demonize their childbearing. 21Roberts D. E. Killing the black body: race, reproduction, and the meaning of liberty. Vintage Books, New York, NY1999Google Scholar, 22Ross L. Solinger R. Reproductive justice: an introduction (Vol. 1). Oakland, CA: University of California Press. 2017Google Scholar It is imperative that contraceptive access efforts recognize and actively work to avoid perpetuating the harmful impacts this ongoing legacy of reproductive oppression can have on the autonomy and well-being of communities of color and other marginalized communities. In defining this new framework (Figure), we also draw on social ecological theory, which describes how social, environmental, and policy contexts interplay to influence health23Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996; 10: 282-298Crossref PubMed Scopus (1702) Google Scholar to depict multiple levels of influence on contraceptive care delivery and people’s engagement and experiences with the health care system. In the following text, we describe each part of the framework in detail. The historical, social, political, and economic context in the United States fundamentally influences health care delivery. Multiple oppressions, including racism, sexism, and economic injustice, intersect to create the reproductive oppression of people of color; poor people; lesbian, gay, bisexual, transgender, and questioning (or queer) people; and others. Furthermore, cultural and religious biases against contraception, and the stigma associated with sexuality and sexual and reproductive health care, are ever present and can interact with these oppressions. Without explicit attention to the ways in which certain groups are at a disadvantage in engaging with care, programs may inadvertently worsen disparities in sexual and reproductive health and autonomy. In the policy and health systems context, the policies of public and private payers, including those related to the Affordable Care Act, Medicaid, and Title X, 24Snyder A. H. Weisman C. S. Liu G. Leslie D. Chuang C. H. The impact of the Affordable Care Act on contraceptive use and costs among privately insured women. Womens Health Issues. 2018; 28: 219-223Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 25Carlin C. S. Fertig A. R. Dowd B. E. Affordable Care Act’s mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage. Health Aff (Millwood). 2016; 35: 1608-1615Crossref PubMed Scopus (47) Google Scholar, 26KFFMedicaid’s role for women. 2019. https: //www. kff. org/womens-health-policy/fact-sheet/medicaids-role-for-women/Date accessed: August 15, 2019Google Scholar, 27Moniz M. H. Kirch M. A. Solway E. et al. Association of access to family planning services with Medicaid expansion among female enrollees in Michigan. JAMA Netw Open. 2018; 1e181627Crossref PubMed Scopus (23) Google Scholar are well recognized as influencing contraceptive as are clinical and public health such as a focus on reducing unintended pregnancy and J. E. Stevenson A. J. Coleman-Minahan K. et al. Challenging unintended pregnancy as an indicator of reproductive autonomy. Contraception. 2019; 100: 1-4Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar it is also to attention to recognized factors in the health system context that can women’s to have their contraceptive choices or their needs including the providers and from a fundamentally M. The birth of the Google Scholar and the of contraceptive methods with that individuals’ have that highly effective contraceptive methods are particularly to meet the of people of D. et and in for of contraceptive 2016; Full Text Full Text PDF PubMed Scopus Google D. S. et by women at high risk of unintended Sex Reprod Health. PubMed Scopus Google Contraceptive access initiatives should also recognize how they are in community and social including and and and work to build that access and quality within these for family related to the of sexual and reproductive health and the of contraceptive individual health care of can also with people’s to seek contraceptive care and meeting individuals’ contraceptive needs the continuum of care, and after individuals interact with the health care in an The continuum of care in the framework is of and trust and and trust in the framework efforts to people outside the health care system with information and build this is as being and more comprehensive than to marketing services or LARCs to communities. and trust should be to meet people’s needs, provide social support to individuals to seek contraceptive care, people’s to services, and and communities and health care among is also to ensure individuals are refers to efforts needed to address financial and other barriers to accessing contraceptive care, such as and care. are with the full range of contraceptive methods, and that they are all or for is addressing is particularly important to ensure people are not to LARCs of a of access to contraception. for care delivery through such as and and of contraceptive is to access to people in people with and face barriers to through same-day and are also to improve Quality refers to the of contraceptive care and the to which services and meet individuals’ related to contraceptive provision and same-day access to the full range of methods are aspects of quality that have on Gynecologic Practice Long-Acting Reversible Contraception Working GroupCommittee opinion no. 642: increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol. 2015; 126: e44-e48Crossref PubMed Google L. J. Grossman D. for the provision of long-acting reversible contraception: a of 2019; 100: Full Text Full Text PDF PubMed Scopus Google Scholar given the context and ongoing that women of color receive family planning D. A. C. M. A. Women’s on family planning an of by race, and Sex Reprod Health. PubMed Scopus Google Scholar and are more to be to use contraception and have LARC methods than white women among D. Reproductive health and perceptions of quality among and group Sex Reprod Health. PubMed Scopus Google R. 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