When Delaware Gov. Jack Markell took office in 2009, he vowed to bring more opportunities to residents of his state. What was standing in their way, the governor found, was a higher rate of unintended pregnancy than anywhere else in the U.S. So he took actions to reduce unintended pregnancies in the state.
Delaware is making long-acting reversible contraception available at low or no cost to women of childbearing age, thanks in part to a partnership with the nonprofit organization Upstream USA, which trains health care providers and health centers to offer intrauterine devices and birth control implants.
Markell told The Nation’s Health that in his eyes, all other types of opportunities — such as pursuing education, building a career, saving money to buy a home and having healthy birth outcomes — were influenced by whether or not people were able to decide when and how to build their families. A March Guttmacher Institute fact sheet showed that in 2010, Delaware had 62 unintended pregnancies for every 1,000 women ages 15-44 in 2010. The rate was the highest in the nation and accounted for 57 percent of all births in the state.
“I pretty quickly came to the conclusion that this is the most important thing that we can do to help more Delawareans reach their potential,” Markell said.
So with the help of Upstream, Delaware invested $1.75 million in state funding, as well as $13 million in philanthropic giving, to reshape the way Delaware residents access family planning. The initiative, called Delaware Contraceptive Access Now, started not with community education, but with billing.
For many women, one of the best and easiest times to insert an intrauterine device is right after delivering a baby. However, in Delaware, as with many states, the medical reimbursement system did not cover IUD insertion after delivery. Instead, providers had to schedule insertion for their patients’ follow-up well-woman visits, four to six weeks after delivery. The drop-off in seeing patients was substantial, as it cost more money for the women seeking care and there was no medical reason for it.
“These are barriers we find in health care all around the entire country,” Mark Edwards, co-founder of Upstream, told The Nation’s Health. “Health centers were worried about losing money. When you help them understand how to bill and code properly, they break even at a minimum, maybe even make a little money.”
In the last two years or so, Upstream staff have been training Delaware health care workers in all aspects of providing IUDs and implants. Licensed medical providers are taught proper insertion and removal of the devices. Front-of-office staff and health care providers learn best practices on how to counsel patients about their birth control options. And billing staff are advised on coding and billing in order to keep the devices affordable. The coverage is not limited to Medicaid patients or certain insurance providers; all providers in the state are covered, from community health centers to private practice and hospitals. As of late July, Edwards said more than 550 Delaware health care staff had received Upstream training.
Staff at Nemours Alfred I. DuPont Hospital for Children in Wilmington, Delaware, were trained by Upstream staff in February. Krishna White, MD, MPH, chief of the hospital’s division of adolescent medicine and pediatric gynecology, said that the hospital has already seen the positive effects of offering LARC to its adolescent patients.
The American College of Obstetricians and Gynecologists recommends LARC as a first line of defense for teens looking to prevent pregnancy. IUDs and implants are the most effective forms of reversible birth control, according to the Centers for Disease Control and Prevention. However, short-acting contraceptives such as condoms and birth control pills are both more popular with teens and less effective.
An April 2015 study from CDC found that less than 5 percent of teens using birth control choose LARC, and many of them know little about the option.
Delaware health center workers practice inserting and removing IUDs during an Upstream USA training earlier this year. IUDs and implants are the most effective forms of reversible birth control, according to CDC.
Photo courtesy Upstream USA
“The majority of patients we see are young women coming in for reproductive concerns,” White told The Nation’s Health. “It’s critically important for teens, who may not be able to make it into another office, or might change their mind. It’s best to provide it for them at the moment they want it.”
While Delaware is working to make LARC available to residents, it is not alone. Colorado’s Family Planning Initiative, which helps Title X clinics offer low- to no-cost IUDs to teens and women who want them, helped lower the state’s teen birth and abortion rates by 48 percent each from 2009 to 2014, according to the Colorado Department of Public Health and Environment. The program has also been associated with better birth outcomes, according to a study published in the September 2015 issue of APHA’s American Journal of Public Health.
Thanks to the program, one in three patients of Title X clinics, which are federally funded to provide family planning options, now uses long-acting reversible contraceptives for their family planning methods, said Jody Camp, MPH, family planning section manager at the Colorado Department of Public Health and Environment.
Along with state support and funding from both state and philanthropic donations, Camp said the media helped in making the program successful in Colorado.
“It’s been so helpful in normalizing our work,” Camp told The Nation’s Health. “They can speak to people on both sides of the aisle. It’s really helped to gain a better understanding about LARC, not necessarily as a tool for birth control, but a tool for economic self-sufficiency. I do believe that’s what (worked) in our favor when we asked the legislature for additional funding.”
Another contributing factor to success, however, is the financial payoff for states. Colorado estimated that its LARC program saved the state $49 million to $111 million in Medicaid birth-related costs. While Delaware’s program is still new, Markell noted that healthy Medicaid births cost the state approximately $12,000, and unhealthy births cost even more.
Upstream’s Edwards said he hopes that more states, cities and clinics will enact programs to make LARC more accessible to those who want it.
“This is really an opportunity to demonstrate that this kind of investment can reduce unintended pregnancies and improve birth outcomes…improve opportunities and also save a lot of money,” he said.
To learn more about the Delaware program, visit www.upstream.org/delawarecan.
- Copyright The Nation’s Health, American Public Health Association
