Prescription Contraceptive Use Research Articles

Impact of the Affordable Care Act on Prescription Contraceptive Use and Costs Among Privately Insured Women, 2006–2020

BackgroundIn the years immediately following the Affordable Care Act (ACA)'s contraceptive coverage requirement, out-of-pocket costs fell for all Food and Drug Administration–approved contraceptive methods and use of long-acting reversible contraception (LARC) increased. This analysis examines whether these trends have continued through 2020 for privately insured women. MethodsUsing 2006–2020 MarketScan data, we examined trends in prescription contraceptive use and out-of-pocket costs among women 13 to 49 years old. Multivariable analyses model the likelihood of contraceptive use and paying $0 post-ACA requirement (vs. pre-ACA requirement) for contraception, controlling for age group, U.S. region, urban versus rural, and cohort year. ResultsThe likelihood of LARC insertion increased post-ACA requirement (adjusted odds ratio [aOR] 1.127, 95% confidence interval [CI] 1.121–1.133), with insertion rates peaking at 3.73% for intrauterine devices (IUDs) and 1.08% for implants in 2019, before declining with the onset of the COVID-19 pandemic in 2020. Although the likelihood of paying $0 for LARC increased after the ACA requirement (IUD: aOR 5.495, 95% CI 5.278–5.716; implant: aOR 7.199, 95% CI 6.992–7.412), the proportion of individuals paying $0 declined to 69% for IUDs and 73% for implants in 2020, after having peaked at 88% in 2014 and 90% in 2016, respectively. For oral contraceptives, both use (aOR 1.028, 95% CI 1.026–1.030) and paying $0 (aOR 20.399, 95% CI 20.301–20.499) increased significantly after the ACA requirement. ConclusionWith the exception of oral contraceptives, the proportion of individuals paying $0 for all contraceptive methods declined after peaking in 2014 for IUDs, 2016 for the implant, and 2019 for non-LARC methods. Future monitoring is needed to understand the continuing impact of the ACA requirement on prescription contraceptive use and costs.

EPH34 Trends in Prescription Contraceptive Use Among US Commercially Insured Women, 2017 – 2021

This study examined trends in prescription contraceptives in 2017-2021 among US women of childbearing ages (16 to 49) before and during the Covid-19 pandemic.

Ectopic pregnancy prevention: Further evidence of benefits of prescription contraceptives

ObjectiveTo estimate the incidence of ectopic pregnancy (EP) associated with prescription contraceptive use. Study DesignWe performed a retrospective cohort study of women aged 15 to 44 years at Kaiser Permanente Northern and Southern California during 2010 to 2019. We identified EPs and prescription contraceptive use from diagnosis, procedural, and medication codes, and natural language processing of clinical notes from electronic health records. Contraceptive use categories included combined hormonal contraceptives, intrauterine devices, depot-medroxyprogesterone acetate (DMPA), progestin-only pills (POPs), implants, no method after recent discontinuation of a prescription contraceptive in the last 12 months, and no method after discontinuation of a prescription contraceptive more than 12 months ago or no use of prescription contraceptives during the study period. Contraceptive use was updated as women started, stopped, or changed methods. An EP was attributed to a contraceptive method if it occurred 14 days after starting and up to 42 days after stopping a method. Age-adjusted EP incidence and 95% confidence intervals (CI) were estimated per 10,000 woman-years overall and by contraceptive category. ResultsThere were 11,436 EPs among 3,204,118 women with 11,909,842 woman-years of follow-up for an overall EP incidence of 9.5 per 10,000 woman-years (95%CI 9.3−9.6). The majority of EPs (9662; 84.5%) occurred during no prescription contraceptive use. EP incidence was lowest during DMPA (1.8 per 10,000 woman-years [95%CI 1.2−2.5]) or implant (2.0 per 10,000 woman-years [95%CI 1.2−3.3]) use, and higher during POP use at 15.2 (95%CI 12.2−19.6); however, incidence was highest after recent discontinuation of a prescription contraceptive (20.6 per 10,000 woman-years [95%CI 19.7-21.4]). ConclusionsEP incidence is lower with prescription contraceptive use than with nonuse. ImplicationsAll prescription contraceptives, including POPs are protective of EP.

The association between depression and contraceptive behaviors in a diverse sample of new prescription contraception users

ObjectiveAmong women initiating new prescription contraception, we investigated the relationship between recent depression and a range of contraceptive behaviors. Study DesignWe used medical and pharmacy records of 52,325 women ages 19 to 29 who initiated prescription contraception (pills, patches or rings, injectables, and long-acting reversible contraceptives) in 2014−2016 at a large integrated healthcare system in Northern California. Women had continuous enrollment for a year before and after initiating, and no records of prescription contraceptive use in the year before initiating. Depression in the year prior to initiation was dichotomized into (1) no depression indicator (reference group) or (2) depression diagnosis or redeemed antidepressant. Multinomial logistic regression models examined the associations between depression and method type initiated, and contraceptive patterns, timing of discontinuation, inconsistent use, and switching methods over a year after initiating, adjusting for sociodemographics and testing for interactions between depression and having a recent birth or abortion. ResultsWomen with recent depression were more likely to initiate methods other than the pill, and the association was stronger for patches or rings vs pills among those with a recent birth compared to those without. Among women initiating all methods and the pill, those with depression were more likely to discontinue their method, use it inconsistently, and switch from it than use it continuously for a year. ConclusionWomen with recent depression were less likely to initiate the pill; and when the pill was initiated, those with depression were more likely to discontinue use, use it inconsistently, and switch from it. ImplicationsWomen with recent depression indicators should be followed closely to ensure they have the support they need to meet their reproductive goals. Those who wish to avoid pregnancy may benefit from methods that do not require daily use.

Efficacy and Cost-Benefit of Onsite Contraceptive Services With and Without Incentives Among Women With Opioid Use Disorder at High Risk for Unintended Pregnancy

Rates of in utero opioid exposure continue to increase in the US. Nearly all of these pregnancies are unintended but there has been little intervention research addressing this growing and costly public health problem. To test the efficacy and cost-benefit of onsite contraceptive services with and without incentives to increase prescription contraceptive use among women with opioid use disorder (OUD) at high risk for unintended pregnancy compared with usual care. A randomized clinical trial of 138 women ages 20 to 44 years receiving medication for OUD who were at high risk for an unintended pregnancy at trial enrollment between May 2015 and September 2018. The final assessment was completed in September 2019. Data were analyzed from October 2019 to March 2021. Participants received contraceptive services at a clinic colocated with an opioid treatment program. Participants were randomly assigned to receive 1 of 3 conditions: (1) usual care (ie, information about contraceptive methods and community health care facilities) (n = 48); (2) onsite contraceptive services adapted from the World Health Organization including 6 months of follow-up visits to assess method satisfaction (n = 48); or (3) those same onsite contraceptive services plus financial incentives for attending follow-up visits (n = 42). Verified prescription contraceptive use at 6 months with a cost-benefit analysis conducted from a societal perspective. In this randomized clinical trial of 138 women (median age, 31 years [range, 20-44 years]), graded increases in verified prescription contraceptive use were seen in participants assigned to usual care (10.4%; 95% CI, 3.5%-22.7%) vs contraceptive services (29.2%; 95% CI, 17.0%-44.1%) vs contraceptive services plus incentives (54.8%; 95% CI, 38.7%-70.2%) at the 6-month end-of-treatment assessment (P < .001 for all comparisons). Those effects were sustained at the 12-month final assessment (usual care: 6.3%; 95% CI, 1.3%-17.2%; contraceptive services: 25.0%; 95% CI, 13.6%-39.6%; and contraceptive services plus incentives: 42.9%; 95% CI, 27.7%-59.0%; P < .001) and were associated with graded reductions in unintended pregnancy rates across the 12-month trial (usual care: 22.2%; 95% CI, 11.2%-37.1%; contraceptive services: 16.7%; 95% CI, 7.0%-31.4%; contraceptive services plus incentives: 4.9%; 95% CI, 0.6%-15.5%; P = .03). Each dollar invested yielded an estimated $5.59 (95% CI, $2.73-$7.91) in societal cost-benefits for contraceptive services vs usual care, $6.14 (95% CI, $3.57-$7.08) for contraceptive services plus incentives vs usual care and $6.96 (95% CI, $0.62-$10.09) for combining incentives with contraceptive services vs contraceptive services alone. In this randomized clinical trial, outcomes with both onsite contraceptive service interventions exceeded those with usual care, but the most efficacious, cost-beneficial outcomes were achieved by combining contraceptive services with incentives. Colocating contraceptive services with opioid treatment programs offers an innovative, cost-effective strategy for preventing unintended pregnancy. ClinicalTrials.gov Identifier: NCT02411357.

History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans

Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services. The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care. Cross-sectional data from a national random sample of women veterans (n= 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n= 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex. Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex. Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.

Contraceptive methods of privately insured US women with congenital heart defects

The American Heart Association recommends women with congenital heart defects (CHD) receive contraceptive counseling early in their reproductive years, but little is known about contraceptive method use among women with CHD. We describe recent female sterilization and reversible prescription contraceptive method use by presence of CHD and CHD severity in 2014. Using IBM MarketScan Commercial Databases, we included women aged 15 to 44 years with prescription drug coverage in 2014 who were enrolled ≥11 months annually in employer-sponsored health plans between 2011 and 2014. CHD, CHD severity, contraceptive methods, and obstetrics-gynecology and cardiology provider encounters were identified using billing codes. We used log-binomial regression to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to compare contraceptive method use overall and by effectiveness tier by CHD presence and, for women with CHD, severity. Recent sterilization or current reversible prescription contraceptive method use varied slightly among women with (39.2%) and without (37.3%) CHD, aPR = 1.04, 95% CI [1.01-1.07]. Women with CHD were more likely to use any Tier I method (12.9%) than women without CHD (9.3%), aPR = 1.41, 95% CI [1.33-1.50]. Women with severe, compared to non-severe, CHD were less likely to use any method, aPR = 0.85, 95% CI [0.78-0.92], or Tier I method, aPR = 0.84, 95% CI [0.70-0.99]. Approximately 60% of women with obstetrics-gynecology and <40% with cardiology encounters used any included method. There may be missed opportunities for providers to improve uptake of safe, effective contraceptive methods for women with CHD who wish to avoid pregnancy.

The Relationship Between Insurance Coverage and Use of Prescription Contraception by Race and Ethnicity: Lessons From the Affordable Care Act.

We describe contraception use by race and ethnicity before and after the Affordable Care Act (ACA) and assess the relationship between insurance coverage and prescription contraception use in both periods. Using data for women ages 15 to 45 at risk of unintended pregnancy from the 2006-2010 and 2015-2017 National Surveys of Family Growth, we examined changes in patterns of contraception use over time by race and ethnicity. We also examined changes in insurance coverage over the same period and considered how the relationship between insurance coverage and prescription contraception use has changed over time within each racial and ethnic group using both descriptive and multivariate regression methods. Before the ACA, Black and Hispanic women were less likely than White women to use prescription contraception by 13.2 and 9.9 percentage points, respectively. After the ACA Medicaid and Marketplace coverage expansions, all groups experienced a decrease in uninsurance, but only Black women experienced a significant increase in prescription contraception use. As a result, the post-ACA Black-White difference in prescription contraception use narrowed to 3.9 percentage points, and the Hispanic-White gap remained unchanged. Our results suggest that, despite significant declines in uninsurance under the ACA, there was no increase in use of prescription contraception for White or Hispanic women. Moreover, the decrease in uninsurance among Black women did not fully explain the large increase in use of prescription contraception for this population.

Reproductive Life Planning and Contraceptive Action Planning for Privately Insured Women: The MyNewOptions Study.

Although reproductive life planning (RLP) is recommended in federal and clinical guidelines and may help insured women make personalized contraceptive choices, it has not been systematically evaluated for effectiveness. In 2014, some 984 privately insured women aged 18-40 who were not intending to become pregnant in the next year were randomly assigned to receive RLP, RLP with contraceptive action planning (RLP+) or information only (the control group). Women's contraceptive use, prescription contraceptive use, method adherence, switching to a more effective method, method satisfaction and contraceptive self-efficacy were assessed at six-month intervals during the two-year follow-up period. Differences between groups were identified using binomial logistic regression, linear regression and generalized estimating equation models. During the follow-up period, the proportion of women using any contraceptive method increased from 89% to 96%, and the proportion using a long-acting reversible contraceptive or sterilization increased from 8% to 19%. Contraceptive adherence was high (72-76%) in all three groups. In regression models, the sole significant finding was that women in the RLP+ group were more likely than those in the RLP group to use a prescription method (odds ratio, 1.3). No differences were evident between the intervention groups and the control group in overall contraceptive use, contraceptive adherence, switching to a more effective method, method satisfaction or contraceptive self-efficacy. The study does not provide evidence that web-based RLP influences contraceptive behaviors in insured women outside of the clinical setting. Further research is needed to identify strategies to help women of reproductive age identify contraceptive methods that meet their needs and preferences.

Effect of Service-Branch on Contraception Use and Childbirth Rates Among United States Military Recruits [6H

INTRODUCTION: Unintentional pregnancy is a common problem among US servicewomen, particularly junior enlisted, with negative effects on the mother, infant, and military readiness. METHODS: Secondary analysis of insurance records from 92,072 servicewomen, who attended basic training between 2013 and 2017, examining differences between service-branches in prescription contraception use after 6 months on active duty and childbirth in the first 24 months of active duty using Kaplan-Meier and Cox Regression Analyses. IRB approved. RESULTS: Rates of prescription contraception use after 6-months on active duty varied significantly between branches [Army (18.1%), Air Force (27.4%), Navy (37.6%), and Marines (26.5%); (P<.001)] as did the proportion of women on prescription contraception using longer-acting methods (Depot-medroxyprogesterone, Implant, or Intrauterine) [Army (15.2%), Air Force (17.5%), Navy (54.7%), and Marines (49.8%); P<.001)]. There were significant (P<.001) differences in the rate of childbirth in the first 24 months on active duty between all of the services except the Air Force and Navy (P=.057) [(Army: 11.1% (95% Confidence Interval 10.7-11.5), Air Force 6.0% (5.6-6.4), Navy 6.7% (6.3-7.1), and Marines 8.4% (7.8-9.0)). In multivariable analysis accounting for age and contraception use, there were significant (P<.001) differences between services in the risk of childbirth. For example, the Navy (Hazard Ratio 1.24 (95% Confidence Interval 1.13-1.35)), Marines (1.48 (1.33-1.65)), and Army (1.86 (1.71-2.01)) all had a higher risk than the Air Force. CONCLUSION: Despite access to an identical medical benefit, including free contraception, contraceptive use and pregnancy rates among junior enlisted vary significantly across services. Further study is needed to determine the etiology of these differences.

Cross cultural workers in maternity and child & family health services

In the United States, 45% of pregnancies continue to be unintended. Although many previous studies have focused on external barriers to contraceptive use such as cost or access, fewer studies have evaluated internal barriers such as individual characteristics. We hypothesize that high self-efficacy for contraception will be associated with use of more effective contraceptive methods.The analytic sample is 861 privately insured Pennsylvania women aged 18 to 40 years not intending pregnancy for 12 months at enrollment. Contraceptive self-efficacy (high vs. low) was measured using an eight-item scale. The association of self-efficacy with prescription contraceptive use was determined using multivariable logistic regression adjusting for future pregnancy intention, history of unintended pregnancy, number of live births, non-White race, frequency of sexual intercourse, marital status, and age group.Prescription contraceptive use was higher among those with high self-efficacy (adjusted odds ratio, 1.75; 95% confidence interval, 1.29–2.37).Women with high self-efficacy for contraception had an increased use of prescription contraceptive methods compared with nonprescription methods. Strategies for encouraging effective contraceptive choices in women with low contraceptive self-efficacy should be further studied.

High Self-Efficacy Is Associated with Prescription Contraceptive Use

In the United States, 45% of pregnancies continue to be unintended. Although many previous studies have focused on external barriers to contraceptive use such as cost or access, fewer studies have evaluated internal barriers such as individual characteristics. We hypothesize that high self-efficacy for contraception will be associated with use of more effective contraceptive methods. The analytic sample is 861 privately insured Pennsylvania women aged 18 to 40years not intending pregnancy for 12months at enrollment. Contraceptive self-efficacy (high vs. low) was measured using an eight-item scale. The association of self-efficacy with prescription contraceptive use was determined using multivariable logistic regression adjusting for future pregnancy intention, history of unintended pregnancy, number of live births, non-White race, frequency of sexual intercourse, marital status, and age group. Prescription contraceptive use was higher among those with high self-efficacy (adjusted odds ratio, 1.75; 95% confidence interval, 1.29-2.37). Women with high self-efficacy for contraception had an increased use of prescription contraceptive methods compared with nonprescription methods. Strategies for encouraging effective contraceptive choices in women with low contraceptive self-efficacy should be further studied.

The Impact of Insurance Coverage on Utilization of Prescription Contraceptives: Evidence from the Affordable Care Act

The Affordable Care Act (ACA) mandates that prescription contraceptives be covered by private health insurance plans with no cost sharing. Using medical and prescription claims from a large national insurer, I estimate individual claim rates and out-of-pocket (OOP) costs of prescription contraceptives for 329,642 women aged 13 to 45 who were enrolled in private health insurance between January 2008 and December 2013. I find that OOP spending on contraceptives has decreased sharply since the implementation of the ACA mandate. Using a difference-in-difference model that leverages employer level variation in compliance with the mandate, I estimate the effect of the mandate on use of both short- and long-term methods of prescription birth control. I find that the mandate has increased insurance claims for short-term contraceptive methods (the pill, patch, ring, shot, diaphragms/cervical caps, and prescription emergency contraception) by 4.8 percent and increased initiation of long-term methods (intrauterine devices, implant, or sterilization) by 15.8 percent. Using data from a national survey of reproductive age women during this same time period, a back-of-the-envelope calculation suggests that the mandate increased total use of any method of prescription contraceptive use by 2.95 percentage points among privately insured women in 2013, or a 6.57 percent relative increase. These increases in use of prescription contraceptives among privately insured women in the United States as a result of the ACA mandate have important potential implications for fertility rates, health care spending, and economic outcomes for women and their families.

Trends in contraceptive use according to HIV status among privately insured women in the United States

There is limited information on the patterns and trends of contraceptive use among women living with HIV, compared with noninfected women in the United States. Further, little is known about whether antiretroviral therapy correlates with contraceptive use. Such information is needed to help identify potential gaps in care and to enhance unintended pregnancy prevention efforts. We sought to compare contraceptive method use among HIV-infected and noninfected privately insured women in the United States, and to evaluate the association between antiretroviral therapy use and contraceptive method use. We used a large US nationwide health care claims database to identify girls and women ages 15-44 years with prescription drug coverage. We used diagnosis, procedure, and National Drug Codes to assess female sterilization and reversible prescription contraception use in 2008 and 2014 among women continuously enrolled in the database during 2003 through 2008 or 2009 through 2014, respectively. Women with no codes were classified as using no method; these may have included women using nonprescription methods, such as condoms. We calculated prevalence of contraceptive use by HIV infection status, and by use of antiretroviral therapy among those with HIV. We used multivariable polytomous logistic regression to calculate unadjusted and adjusted odds ratios and 95% confidence intervals for female sterilization, long-acting reversible contraception, and short-acting hormonal contraception compared to no method. While contraceptive use increased among HIV-infected and noninfected women from 2008 through 2014, in both years, a lower proportion of HIV-infected women used prescription contraceptive methods (2008: 17.5%; 2014: 28.9%, compared with noninfected women (2008: 28.8%; 2014: 39.8%, P < .001 for both). Controlling for demographics, chronic medical conditions, pregnancy history, and cohort year, HIV-infected women compared to HIV-noninfected women had lower odds of using long-acting reversible contraception (adjusted odds ratio, 0.67; 95% confidence interval, 0.52-0.86 compared to no method) or short-acting hormonal contraception method (adjusted odds ratio, 0.59; 95% confidence interval, 0.50-0.70 compared to no method). In 2014, HIV-infected women using antiretroviral therapy were significantly more likely to use no method (76.8% vs 64.1%), and significantly less likely to use short-acting hormonal contraception (11.0% vs 22.7%) compared to HIV-infected women not using antiretroviral therapy. Those receiving antiretroviral therapy had lower odds of using short-acting hormonal contraception compared to no method (adjusted odds ratio, 0.45; 95% confidence interval, 0.32-0.63). There was no significant difference in female sterilization by HIV status or antiretroviral therapy use. Despite the safety of reversible contraceptives for women with HIV, use of prescription contraception continues to be lower among privately insured HIV-infected women compared to noninfected women, particularly among those receiving antiretroviral therapy.

Associations Between Perceived Race-based Discrimination and Contraceptive Use Among Women Veterans in the ECUUN Study

To describe perceived race-based discrimination in Veterans Affairs (VA) health care settings and assess its associations with contraceptive use among a sample of women Veterans. This study used data from a national telephone survey of women Veterans aged 18-44 receiving health care in VA who were at risk of unintended pregnancy. Participants were asked about their perceptions of race-based discrimination while seeking VA health care and about their contraceptive use at last heterosexual intercourse. Logistic and multinomial regression analyses were used to examine associations between perceived race-based discrimination with use of prescription contraception. In our sample of 1341 women Veterans, 7.9% report perceived race-based discrimination when receiving VA care, with blacks and Hispanics reporting higher levels of perceived discrimination than white women (11.3% and 11.2% vs. 4.4%; P<0.001). In logistic and multinomial regression analyses adjusting for race/ethnicity, age, income, marital status, parity, and insurance, women who perceived race-based discrimination were less likely to use any prescription birth control than women who did not (odds ratio, 0.65; 95% confidence interval, 0.42-1.00), with the largest difference seen in rates of intrauterine device or implant use (odds ratio, 0.40; 95% confidence interval, 0.20-0.79). In this national sample of women Veterans, over 10% of racial/ethnic minority women perceived race-based discrimination when receiving care in VA settings, and perceived racial/ethnic discrimination was associated with lower likelihood of prescription contraception use, especially intrauterine devices and implants. VA efforts to enhance respectful interactions may not only improve patient health care experiences, but also represent an opportunity to improve reproductive health outcomes for women Veterans.

Prescription contraception use and adherence by women with substance use disorders.

Unintended pregnancy rates are high among women with substance use disorders (SUDs), which could be explained partly by lower use of and adherence to contraception. We aimed to test: (1) the association of SUD with prescription contraceptive use, contraceptive method selection and adherence; (2) whether practices participating in the Patient-Centered Medical Home Initiative (PCMHI) had better contraceptive use and adherence for patients with SUD; and (3) for differences in the association of SUD with adherence by type of contraceptive used. Retrospective cohort analysis of claims and encounter data. Massachusetts, USA. A total of 47 902 women aged 16-45years enrolled in Medicaid or Commonwealth Care in Massachusetts between 2010 and 2014. We examined three dependent variables: (1) use of a reversible prescription contraceptive during 2012; (2) the contraceptive methods used; and (3) the proportion of days covered by a prescription contraceptive in the year following the first prescription contraceptive claim. The primary predictor was diagnosed SUD, defined as at least one claim for an alcohol or drug use disorder. SUD was associated with lower rates of prescription contraceptive use during 2012 [19.2 versus 23.9%; adjusted odds ratio (aOR)=0.79, P<0.001]. SUD was associated with decreased selection of long-acting reversible contraception (LARC) compared with short-acting contraception (SARC) (42.8 versus 44.5%; aOR=0.83, P=0.011). There was no significant association between SUD and adherence (aOR=0.84, P=0.068). PCMHI enrollment did not alter the relationship between SUD and contraceptive use or adherence. Contraceptive method did not impact the relationship between SUD and adherence. Women with substance use disorders are less likely to use prescription contraceptives, especially long-acting methods, but are not significantly less likely to adhere to them once prescribed than women without substance use disorders.

Using behavioral economic theory to increase use of effective contraceptives among opioid-maintained women at risk of unintended pregnancy

ObjectiveAn unsettling aspect of the US opioid epidemic is the high rate of in utero exposure, especially since most of these pregnancies are unintended, due in part to low rates of effective contraceptive use among opioid-using women. This study tested an intervention informed by behavioral economic theory and aimed at promoting effective contraceptive use among opioid-maintained women at risk of unintended pregnancy in the Burlington, VT, area between 2011 and 2013. MethodsThirty-one women were assigned (initial 5 consecutively, subsequent 26 randomly) to either usual care or an experimental intervention. Participants in usual care received condoms, a dose of emergency contraception, and referral to local providers. Participants in the experimental condition received usual care plus the World Health Organization's contraception initiation protocol, including free prescription contraceptives, and financial incentives for attending 13 follow-up visits over 6months to help manage side effects and other issues. ResultsSignificantly more women in the experimental vs. usual care control conditions initiated prescription contraceptive use (100% vs. 29%) and reported prescription contraceptive use at 1-month (63% vs. 13%), 3-month (88% vs. 20%), and 6-month (94% vs. 13%) assessments. None of the experimental condition participants became pregnant during the 6-month protocol vs. three women (20%) in the control condition. ConclusionsThese results provide the first experimental evidence supporting the efficacy of an intervention for increasing prescription contraceptive use among opioid-maintained women at risk of unintended pregnancy.

A Qualitative Study of Prescription Contraception Use: The Perspectives of Users, General Practitioners and Pharmacists.

BackgroundThe oral contraceptive pill (OCP) remains the most popular form of prescription contraception in many countries, despite adherence difficulties for many. Uptake of long acting reversible contraceptives (LARCs), which are less reliant on user adherence, remains low. The aim of this study was to explore the experiences of, and attitudes towards, prescription contraception amongst samples of contraception users, general practitioners (GPs) and pharmacists.Methodology and FindingsWe conducted a qualitative study using semi-structured interviews with 18 contraception users, 18 GPs and 9 pharmacists. The study took place in Galway, Republic of Ireland between June and September 2014. Thematic analysis was used to analyse the data. Overall, contraception users were more familiar with the OCP, and all the women interviewed began their prescription contraception journey using this method. All participants identified episodes of poor adherence throughout the reproductive life course. The identified barriers for use of LARCs were lack of information, misconceptions, lack of access and high cost. In contrast, GPs believed that adherence to the OCP was good and stated they were more likely to prescribe the OCP than other methods, as they were most familiar with this option. Barriers to prescribing LARCSs were time, cost to practice, training and deskilling. Pharmacists also believed that adherence to the OCP was generally good and that their role was limited to dispensing medication and providing information when asked.Discussion and ConclusionThere are contrasting perspectives between contraception service providers and contraceptive users. Training for healthcare providers is required to support informed contraceptive choice and adherence. It is necessary to address the practice barriers of cost and lack of time, to promote better communication around adherence issues and prescription contraception options. There is a need for more easily-accessible public health information to promote awareness on all methods of prescription contraception.

Contraceptive Use Among Women With Medical Conditions in a Nationwide Privately Insured Population.

To examine contraceptive use among women with selected medical conditions. We used a nationwide health care claims database to identify women aged 15-44 years continuously enrolled in private insurance during 2004-2011 with and without selected medical conditions. We assessed current permanent and reversible prescription contraceptive use during October 1, 2010, to September 30, 2011, with diagnosis, procedure, and pharmacy codes and calculated prevalence by age and condition. We used polytomous logistic regression to calculate odds of female sterilization or reversible prescription methods compared with neither. Among users of reversible methods, we used logistic regression to calculate odds of using long-acting reversible contraceptives compared with shorter acting methods. A low proportion of women with medical conditions were using sterilization or reversible prescription methods (45% and 30% of women aged 15-34 and 35-44 years, respectively), and this proportion was consistently lower among the older age group across all medical conditions. Across both age groups, sterilization and long-acting reversible contraceptives were used less frequently than shorter acting methods (injectable, pill, patch, or ring). The odds of sterilization were higher among women with any compared with no condition for women aged 15-34 years (odds ratio [OR] 4.9, 95% confidence interval [CI], 4.5-5.3) and 35-44 years (OR 1.2, 95% CI, 1.1-1.2). Among women using reversible prescription methods, the odds of using long-acting reversible contraceptives were increased among those with any compared with no condition for women aged 15-34 years (OR 2.2, 95% CI, 2.1-2.5) and 35-44 years (OR 1.1, 95% CI, 1.1-1.2). Despite the potential for serious maternal and fetal pregnancy-associated risks, contraceptive use was not optimal among women with medical conditions. III.

Mandating Prescription Contraception Coverage: Effects on Contraception Consumption and Preventive Health Services

While recent national discussions of the Affordable Care Act (ACA) made the introduction of mandated contraceptive coverage within health insurance policies seem like a novel idea, it is not new at all. Since the late 1990s, 29 states have mandated that insurance providers include prescription contraceptive supplies and, in some instances, associated contraceptive services in their coverage. We use state-level policy variation to generate both difference-in-differences and triple difference estimates to determine if women in states with state-level contraception supply or contraception supply and services insurance mandates experienced changes in their utilization of contraception and preventive health care services. We find a positive relationship between these policies and prescription contraception use for those with low educational attainment, but the results are not robust to a variety of specifications. Our results also show an increase in the consumption of preventive health services for women with low educational attainment as a result of these health insurance mandates. We conclude by discussing the implications for the ACA.