I've written before about the Colorado Family Planning Initiative, which in 2009 started providing free IUDs and contraceptive implants (the two forms of long-acting reversible contraception, or LARC) to low-income women at family planning clinics in 37 Colorado counties. Between 2008 and 2014, the state's teen birth and abortion rates both dropped by 48% (see this webinar for details). While teen birth rates have been declining nationwide in recent years, Colorado's decline was the largest.
LARC methods have become increasingly popular in the US over the past several years. This is likely due in part to women and providers alike becoming increasingly familiar with these methods' safety, efficacy, and suitability. In particular, IUDs' popularity suffered after the Dalkon Shield, which had a flawed design and was associated with serious -- and in some cases, fatal -- negative health effects in the 1970s. (While many women in Europe continued to use other IUDs after sales of the Dalkon Shield were suspended, the vast majority of US women using contraception chose other methods.) IUDs were also originally approved only for women who had already given birth, but the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics now recommend both IUDs and implants for teens and other women seeking to avoid pregnancy, whether or not they've had children. The main benefit of these methods is that they don't rely on people remembering to do something every day or before every act of intercourse (like pills and barrier methods do), and as a result their failure rates are below 1%.
While familiarity with LARC methods has grown substantially over the past decade, cost can remain a barrier. The devices generally cost $500 - $1,000, which is steep for both women and providers. The Affordable Care Act requires most employer-sponsored insurance plans to cover at least one of each form of FDA-approved prescription contraceptives without cost-sharing (i.e., women shouldn't owe co-payments for either the device or related visits). This has put IUDs and implants within financial reach for many more women -- although it may take a while before all non-exempt employers are fully compliant with this ACA provision. Medicaid must cover family planning services without cost-sharing, but specific benefits can vary by state, and not all states have accepted the ACA's Medicaid expansion.
Many low-income women obtain contraception from Title X providers, who receive federal grants in order to provide family-planning services on a sliding-scale fee basis to low-income men and women. In these cases, the cost barrier may not be just women's out-of-pocket costs, but the cost to the Title X provider of keeping IUDs and implants in stock. Even with special pricing, Title X clinics can pay $300 - $500 for each LARC device. (One new exception to this is the Lileta IUD, approved by FDA in 2015; its manufacturer, the nonprofit company Medicines360, is making it available to providers in the 340B program for $50.) When many Title X clients pay $0 or a very small amount for the services they receive, it's not financially sustainable for providers to buy and insert a lot of LARC devices. The Colorado Family Planning Initiative gave Title X providers money to buy IUDs and implants, and to undertake other activities like staff training that were necessary in order to serve more clients and provide free LARC to women who opted for an IUD or implant.
Think of the children!
Over the summer, the US House of Representatives Appropriations Committee released a funding bill that would have eliminating all federal funding for the Title X program. Crippling the Title X program would have been terrible for public health, so I was relieved when the FY2016 Omnibus Appropriations Act kept Title X funding at its FY 2015 level. However, the House proposal made me suspect that many members of Congress don't care sufficiently about healthcare for low-income women. But everyone cares about children, right? And a recent study from Colorado, published in the American Journal of Public Health in September, finds that pre-term births in Colorado dropped significantly after access to LARC improved.
Lisa M. Goldthwaite and colleagues from the University of Colorado used data from the Colorado Department of Public Health and the Environment to analyze births to Colorado women in 2008, before the CFPI began, and in 2012, after it had been fully implemented. For each birth, they captured the woman's county of residence as well as other demographic and health information. The researchers examined the relationship between county of residence and two adverse pregnancy outcomes, preterm birth and low birthweight.
The CFPI provided funds to Title X-funded agencies that served 37 of the state's 64 counties. The authors compared birth outcomes for women living in Title X counties to those living in counties without Title X clinics. In addition, for each of the Title X counties, they calculated the percentage of Title X clients who were using LARC methods, out of all the women using contraception at that county's Title X clinics. These counties were then grouped into quartiles.
The authors found that between 2008 and 2012, the total number of clients receiving family-planning services from Title X providers jumped from 46,201 to 64,148, and the percentage of those clients using LARC methods rose from 1% to 9%. Statewide, the authors found a 12% decrease in the odds of preterm birth after adjusting for confounders. When comparing counties with and without Title X providers, they found the odds of preterm birth were significantly lower for women living in counties served by Title X. When comparing Title X counties by proportion of clients using LARC methods, they found the two quartiles with the greatest LARC use to have a significant decrease in preterm births when compared to the quartile with the lowest LARC use. None of the associations for low birthweight were statistically significant. Goldthwaite and her colleagues conclude (emphasis added):
Because of the association found in the present study between LARC use and PTB, increasing LARC uptake at the population level may be an important future direction for public health policy, programming, and research. In particular, our results suggest that providing access to free or affordable highly effective methods of contraception will lead to an overall reduction in rates of PTB. Although the funding provided through the Colorado Initiative ended in 2013, we encourage public health leaders in Colorado and across the United States to provide ongoing advocacy for the support of accessible and affordable family planning services.
Thanks to a group of foundations, the Colorado Family Planning Initiative received enough money to continue through mid-2016. Perhaps results such as these will convince the state's legislators -- and maybe even the US Congress -- to support free access to some of the most effective forms of contraception.
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Did the authors suggest a mechanism by which LARC reduce the incidence of PTB?
The authors didn't discuss a mechanism, though they note that unintended pregnancies are associated with increased risk of adverse pregnancy outcomes -- so, it makes sense to study whether reducing unintended pregnancies also reduces those adverse outcomes.
My guess is that LARC methods help reduce PTB by reducing rapid repeat pregnancies.