A Review of the Accessibility and Affordability of Contraception for Womenâ•Žs Self-care and Reproductive Health

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A Review of the Accessibility and Affordability of Contraception A Review of the Accessibility and Affordability of Contraception

for Women’s Self-care and Reproductive Health for Women’s Self-care and Reproductive Health

Alexis Henderson

Philadelphia College of Osteopathic Medicine

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and Reproductive Health" (2021).

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Philadelphia College of Osteopathic Medicine

Graduate Program in Biomedical Sciences

School of Health Sciences

A REVIEW OF THE ACCESSIBILITY AND AFFORDABILITY OF

CONTRACEPTION FOR WOMEN’S SELF-CARE

AND REPRODUCTIVE HEALTH

A Capstone in Public and Population Health Leadership by Alexis Henderson

Submitted in Partial Fulfillment of the Requirements for the Degree of

Master of Science in Biomedical Sciences, Public and Population Health Leadership

Concentration

May 2021

ABSTRACT

The use of contraception has afforded many women the opportunity to gain

control over their reproductive health while also advancing their education and career

goals. Additionally, hormonal contraceptives have improved women’s quality of life by

treating and preventing specific clinical symptoms and conditions. Nonetheless,

disparities and barriers to accessing affordable reproductive care still affect many

populations of women. This study examines the accessibility and affordability of

contraception for women’s reproductive and self-care needs, including treating and

preventing clinical symptoms, conditions, and pregnancy. A literature review of PubMed

databases was completed for studies in the United States between January 2013 and May

2021. Studies were chosen based on examining the perceptions, barriers, and advantages

of acquiring accessible and affordable hormonal contraception on women’s health.

Though many women benefit from contraceptive use throughout various stages of their

lives, specific populations of women experience disparities and barriers to accessing

quality and affordable reproductive care. Many of these barriers include lack of

knowledge, patient-provider power dynamics, desire for autonomy in one’s reproductive

health, insurance or cost constraints, and additional policies and actions restricting

reproductive and contraceptive care availability. Expanding women-focused education,

services, and policies to address these barriers systematically can improve the

accessibility and affordability of contraceptive and reproductive care and enhance the

quality of women’s health and self-care.

INTRODUCTION

Women have faced many challenges in accessing quality and affordable health

care for centuries. Women’s health is defined as the promotion, maintenance, and

restoration of the physical, psychological, social, and numerous other concerns that affect

women’s well-being (1). Major issues previously affecting women’s health included

increased health premiums and denial or lack of coverage for essential services, including

maternal care, mental health care, and prescriptions for contraceptives (1). The Women’s

Health Movement sparked initial changes to address the gaps in women’s health by

providing women control over their reproductive rights, including women as key players

in clinical research and increasing awareness of the worldwide violence and

discrimination against women (1). Over the years, federal policies regarding women’s

health care have shifted. Implementation of the Affordable Care Act in 2014 expanded

coverage for reproductive-aged women to improve health insurance coverage and limit

cost-related barriers. Nonetheless, there continue to be prevalent risks to accessing

quality and affordable preventative and reproductive services for many women.

Contraception methods have been a critical preventative health service used to

reduce unintended pregnancies over the years. Contraceptive use has contributed to

improving women’s self-care and well-being, providing autonomy in making decisions

about one’s health, and positively impacting families, communities, and society. Types of

contraceptive methods are divided into hormonal contraceptives and nonhormonal

contraceptives for protective measures and emergency contraceptives used after sexual

intercourse. Nonhormonal contraceptives include condoms, vaginal sponges, and

diaphragms. Hormonal contraceptive methods include the pill, patch, ring, and

injectables, categorized as either combined estrogen-progestin or progesterone-only.

Another method of hormonal contraceptives includes long-acting reversible contraception

(LARC), which involves hormonal implant devices. The efficacy of these contraceptive

methods to prevent unintended pregnancies is highest with either the LARC, combined

estrogen-progestin, or progesterone-only methods (2). The nonhormonal methods are the

least efficient (2).

In 2018, more than 99% of sexually active women between the ages of 15 to 44

reported using some form of contraception in their lifetime (2). Various contraceptive

methods have contributed to women’s societal advancement by limiting unwanted

pregnancies while prioritizing their own needs and desires, such as achieving their

education and career goals. Though contraceptive use has decreased the rates of live

births, unintended pregnancies, and abortions in the United States, these rates remain

relatively high compared to similar countries. Significant reproductive health disparities

are still present among women of color, women with low incomes, and women aged 18

to 24 (3). These women often face difficulties with the accessibility and affordability of

quality healthcare.

Though women have made many improvements historically in the fight for equal

rights, there are still many restrictions limiting women’s rights to reproductive care. The

focus of this review is to address the advantages, barriers, constraints, and disparities of

acquiring accessible and affordable hormonal contraceptives to improve the quality and

availability of services for women’s self-care and reproductive health.

BACKGROUND

In addition to protecting from unintended pregnancies, hormonal contraceptives

have been known to treat and prevent gynecological conditions in women. The combined

estrogen-progestin oral contraceptive pill was initially introduced to treat menstrual

symptoms, such as migraines, excess menstrual blood loss, dysmenorrhea, and

premenstrual syndrome (2). Recent studies have found evidence of the treatment of

various conditions and symptoms specific to women with combined estrogen-progestin

and LARC methods. These hormonal contraceptives have also been found to treat

menorrhagia and acne symptoms while also preventing the development of ovarian

cancer, uterine fibroids, endometriosis, and pelvic inflammatory disease (2).

However, the need for accessible and affordable hormonal contraceptives for the

self-care of young women, postpartum women, and perimenopausal women is often

overlooked. Many young women, including adolescents, experience a high rate of

unintended pregnancies. The reasons for the high rate of young pregnancies include the

inability to access effective preventative care, limited disclosure of sexual status, and lack

of knowledge about reproductive health and contraception options (4). The postpartum

period is ideal for women to initiate contraception to reduce the risk of short birthing

intervals, which can cause preterm birth and low birth weights in newborns (5). Many

women experience changes during the perimenopausal period, including fertility issues,

urogenital changes, and abnormal bleeding. Contraceptive use during the perimenopausal

period can relieve these symptoms and treat problems such as loss of bone mineral

density, irregularities in menstruation, and vasomotor instability, which causes hot

flashes (5). The acquisition and continuation of hormonal contraception have provided

many benefits to improving women's quality of life and self-care at every stage.

The knowledge and use of contraceptives give women the power to exert agency

and advocate for themselves, their future, and their children. Many women have varying

perceptions and satisfaction of different hormonal contraception methods. A prospective

cohort study of 5,000 women found 84% satisfied with the LARC method compared to

53% that used other hormonal contraceptive methods (6). Factors that influence women’s

satisfaction include ease of use, improvements in bleeding and cramping patterns,

perceived effectiveness, and limited side effects (6). However, a large proportion of

women have negative perceptions of hormonal contraception. The most influencing

factors contributing to women’s negative perception of hormonal contraception are cost,

provider bias, lack of provider knowledge or training, and accessibility barriers (7).

Barriers to Affordable and Accessible Contraception for Women

Healthcare providers play an essential role in educating and promoting the health

benefits of contraceptive care while enabling open, patient-centered communication

concerning the unique demands of each woman’s health. Unfortunately, many women’s

misperceptions and unfounded concerns surrounding hormonal contraceptive use are

often enabled by their healthcare providers’ lack of knowledge about the various

methods. Many women prefer to use family planning services that offered LARC

methods compared to other hormonal contraceptives (8). Notably, the LARC method has

the highest satisfaction and effectiveness of use. Still, barriers such as provider

knowledge gaps, prohibiting same-day insertion, and the elimination of immediate

insertion for postpartum women have affected their continuation of use (9). Though 88%

of physicians report providing long-acting hormonal contraceptives, 24% of internal

medicine or pediatric physicians also prescribe and provide these methods (9). This may

be due to the long-term cost of LARC methods being lower than the long-term cost of

monthly refills for pills, patches, or injectables. However, the upfront cost of LARC

methods is more costly than other hormonal contraceptive methods (9). Primary care

physicians are the first-line providers for many women as compared to obstetrician-

gynecologist. However, very few residency programs adequately train students of

different specialties in counseling, prescribing, and providing hormonal contraceptives

(2). A primary care physician will often refer a patient to an obstetrician-gynecologist to

provide contraception counseling or insert a contraceptive device. It would be beneficial

to patients to have primary care specialists also educated, trained and confident in

counseling women on reproductive health and contraceptive options, following the

guidance of the CDC’s Medical Eligibility Criteria (2).

Significant barriers obstruct the affordability and accessibility of effective

women’s reproductive healthcare and contraceptive acquisition. In 2014, the Affordable

Care Act required all private insurance plans to cover all FDA-approved hormonal

contraceptive methods with no out-of-pocket costs. The expansion of Medicaid and

private insurance decreased the proportion of uninsured women from 18.9% in 2012 to

11.5% in 2015, with little to no changes today (10; 11). Despite the Affordable Care

Act’s influence to reduce disparities in women’s health coverage by expanding Medicaid

and private coverage for women of reproductive age, costs of hormonal contraception for

women’s self-care needs remain a significant barrier. Though insurance companies cover

all approved contraceptive methods, coverage varies depending on state and insurer.

Insurance barriers, such as a lack of coverage, cost-sharing, and limiting the number of

products dispersed at a time, cause significant constraints and often lead to

discontinuation of hormonal contraceptive use (12). The American College of

Obstetricians and Gynecologists recommends that payment policies support providing 3-

13 month supplies of oral contraceptives to maintain the individual continuation of use

(12). These barriers pose a challenge to many women as it may become difficult to

maintain routine administration or demanding to access a provider to get a new

prescription.

Additionally, cost-sharing varies between insurance coverage plans. Individual

plans with high out-of-pocket costs, deductibles, and copayments can be barriers to

accessing and maintaining contraceptive services. Previous findings suggest lower cost-

sharing can increase the use of effective contraceptive methods (13). Even with

reproductive care covered by publicly and privately owned insurance plans, women still

pay 60% out-of-pocket costs for contraception methods compared to 33% for non-

contraceptive drugs (12).

Though the Accessible Care Act of 2014 increased insurance coverage for

women’s health and preventative care, women saw little to no change in their ability to

access care. Several structural barriers limit women’s accessibility to contraceptive care.

Contraceptive services often require an annual physician visit to be screened, counseled,

get a prescription, then obtain the chosen contraceptive method, frequently from a

pharmacy. The requirement for annual medical screenings and multiple provider visits is

sometimes a deterrent for many women, often supported by some insurer payment

policies (12). Though physician screenings and counseling are beneficial to assist

individuals in making the best decision to initiate contraceptive use depending on their

health status, annual pelvic examinations and cervical cytology can discourage a woman

from continuing the use of a particular method. Some providers also refuse same-day

services for contraceptives, such as LARC and other hormonal methods, to acquire a

pregnancy test before inserting the implant device. However, there are instances in which

a pregnancy test is not needed, such as when the last menstruation was less than seven

days ago or if a patient has not had unprotected sex since the last menstrual cycle (9).

Additionally, inconvenient office hours, a limited range of method knowledge, and

availability also pose a challenge for women accessing or continuing contraceptive care.

Expanding women’s access to reproductive and contraceptive care by removing the

financial and structural barriers to access providers and clinics should continue to be an

important goal of women’s health while also ensuring women’s preferences and desires

are the focus.

Additionally, federal, state, and local restrictive policies and legislature interfere

with the provision and coverage surrounding the accessibility and affordability of

contraception and reproductive services. The Affordable Care Act of 2014 aimed to

improved coverage for essential women’s health services; however, specific coverage

exclusions continue to prevent women from receiving quality and affordable preventative

and reproductive services (14). In 2018, Trump also released two rulings allowing

exemptions for employees in covering women’s contraceptive care due to religious

beliefs or nonreligious moral objections (15). These unfavorable rulings act to interfere

with women’s access to contraceptive services and the patient-physician relationship.

Minors are currently restricted in 20 states from acquiring contraceptive services even

with parental consent (12). Conversely, the American College of Obstetricians and

Gynecologists recommends and supports accessible and affordable women’s health and

contraceptive care for all (12).

RESEARCH STRATEGIES

A literature review of the PubMed database was conducted to review articles and

studies in the United States between January 2013 to May 2021. The studies sampled or

examined experiences of reproductive-aged women 15 to 44 years old. Studies were

chosen based on examining the benefits, perceptions, difficulties, and challenges

affecting the accessibility and affordability of women’s reproductive health regarding

acquiring hormonal contraceptives. To select studies, a keyword search, with Boolean

phrases AND/OR, was used involving the following terms: female, women, women’s

health, contraception, contraceptives, health care, preventative care, women’s self-care,

self-care, access, accessibility, hormonal contraception, reproductive health, health

service, reproductive health service, women’s health care, affordability, cost, women’s

preventative care, insurance barriers, insurance constraints, policies, laws, Affordable

Care Act. Additional phrases searched included: challenges in access, barriers in access,

improvements in access, challenges in affordability, barriers in affordability,

improvements in affordability, challenges in cost, barriers in cost, improvements in cost.

No hard copy journal searches were conducted. Criteria for inclusion included women of

reproductive age, a focus on women’s health beyond protecting from unintended

pregnancies, and facilitating or limiting factors affecting accessible and affordable

acquisition of contraceptives for women’s self-care and reproductive health. Recent

advancements and innovations to accessing affordable contraceptive care were also

searched and reviewed to improve women’s health.

DISCUSSION

The affordability and accessibility of health services for women’s reproductive

health and self-care have progressed over the years. Nonetheless, many improvements are

still necessary. The implementation of the Affordable Care Act of 2014 expanded

coverage for women’s preventative health services, which included contraceptive

counseling and care. Unfortunately, many women still deal with increased out-of-pocket

spending, cost-sharing effects, and obstacles to accessing reproductive health services.

There is also a need to improve provider knowledge deficits to counsel women in

choosing a safe contraceptive method under the U.S. Medical Eligibility Criteria for

Contraceptive Use guidelines. Obstetrician gynecologists, internal medicine providers,

and pediatricians can be strong advocates for safe, affordable contraceptive access. As

women require different health resources throughout their lifetime to maintain power

over their health and lives, open, patient-centered communication and care should be

supported to enable women to make informed choices about their reproductive and self-

care health maintenance.

To Improve the Affordability of Hormonal Contraceptives

The expansion of insurance plans to cover all FDA-approved contraceptive

methods may have assisted in coverage for many women’s preventative care services;

however, out-of-pocket costs did not change. Privately insured women saw an increase

in out-of-pocket expenses due to cost-sharing effects (13). In contrast, publicly insured

women, such as those under Medicaid, saw decreased out-of-pocket costs (13). Women

already face increased financial challenges due to low incomes. Being burdened by

increased out-of-pocket costs is another way to limit the power women have over their

health. Though the Affordable Care Act seemed effective in transferring some of the cost

burdens away from women, it may be a while before cost-sharing is eliminated.

Studies have shown women, insured and uninsured, still face burdens being able

to afford specialist care, prescription medications, screenings, multiple visits, and annual

STD and pelvic examinations (16). Health policies, organizations, and insurance

companies should eliminate cost-sharing to obtain women’s reproductive and self-care

services. Diminishing cost-sharing has the potential to lead to increased contraceptive

continuation. A lower out-of-pocket cost may also be the difference between choosing a

contraceptive method over another and considering personal lifestyle and health status.

Diminishing copayments, high deductibles, and coinsurance for comprehensive

contraceptive services and prescriptions may increase adherence to contraceptive use for

women’s reproductive and self-care maintenance.

To Improve the Accessibility of Hormonal Contraceptives

Expanded access to affordable preventative care has contributed to many benefits

for women’s health; however, threats to comprehensive reproductive services still exist.

In 2020, there was an increase in women who saw or talked to a physician in the past 12

months (16). Nonetheless, gaps in access to quality reproductive care are still a barrier to

overcome. Providers should be educated in counseling, prescribing, and providing

contraceptive options to women of all ages. There should be increased access to newer,

safer formulations for oral contraceptive methods and an increase in the availability of

LARC methods (17). Minority and low-income women have often been prescribed

LARC methods without regard to their personal health histories or status (17). Physician

training programs and organizations should aim to overcome provider bias in the

counseling and providing of hormonal contraceptives and instead consider individual

women’s unique health needs and desires for reproductive and self-care.

Access to contraception should be universally unrestricted by the government to

improve the quality of life for women throughout their lifespan. New legislation, enacted

in 2017, has expanded access to contraception in 22 states plus Washington, D.C., to

provide a year-long supply of all forms of self-administered hormonal contraceptive

methods (18). This law aimed to increase method continuation, including the provision

and use of combined and progestin-only oral contraceptive pills, the vaginal ring, and the

patch (18). There remain obstacles in the full implementation of this law, such as store

policies and insurance reimbursement challenges, that must be addressed. Patients,

providers, and prescribers must be informed of this new law to advocate for the

development of new protocols and personnel training in pharmacies and insurance

companies (18). Overall, all women have the right to affordable and accessible health

services without restriction from the government or insurance companies for self-care

and reproductive health throughout various stages of their life span to maintain optimal

health and achieve personal goals.

RECOMMENDATIONS FOR FUTURE STUDIES

Future studies should take into account the deficits in research considering

expanding access to adolescents, strengthening insurance coverage, access and

affordability, and the implications of recent innovations on these factors. Expanding

access to hormonal contraceptives for adolescents holds many benefits. Adolescents are

often overlooked in research and policy implementation surrounding hormonal

contraceptive use. Minors should be included in the research, design, and implementation

of expanded hormonal contraceptive options (4). Additionally, advocacy to expand

adolescent access to hormonal contraceptives is necessary if increased access

significantly benefits this population.

The effects of the Affordable Care Act related to coverage, access, and

affordability of comprehensive women’s reproductive health are also critical. There are

many gaps in research regarding the continuation of services for minority communities,

the impact of eliminating cost-sharing, and patient-focused outcomes. There is also a

need to assess the impact of the Affordable Care Act’s expansion on contraceptive brand

use. Because the Act does not mandate insurance companies cover all contraception

brands, the choice of a brand could determine an individual’s out-of-pocket cost for

services (13). An analysis on subgroups that experience the most disparities in care and a

comparison analysis of private insurers to public insurers concerning contraceptive use

and continuation patterns is also lacking in research (16). Overall, improvements in the

policies and stability of insurance plans by expanding Medicaid in all states and

maintaining the Marketplace supports strengthening the accessibility and affordability of

contraceptives for women’s reproductive care.

Additionally, a debate to implement new methods to expand affordable and

accessible contraceptive care has been discussed. Several innovations to increase

contraceptive access for women of all ages are being developed, such as over-the-counter

oral contraceptives, pharmacist prescribing, and web-based telehealth platforms (4).

State-to-state variability in insurance plans, pharmacy prescribing, and telehealth laws are

just some barriers to implementing these innovations to accessible contraceptive care.

Many measures must be considered before implementation of over-the-counter

access to hormonal contraception begins. Products dispensed over-the-counter must have

a low potential for misuse and abuse and limit the potential consequences for

inappropriate self-selection. Over-the-counter access will likely begin with progestin-

only pills, not combined oral contraceptives, due to their safety and low side effects

profile (4). There is currently a lack of legislative mandates, policies, and financial

incentives for insurance companies to implement over-the-counter access to hormonal

contraceptives (19). There is also concern that this method may reduce the need for

routine preventative screenings, such as pap smears, pelvic exams, breast exams, and

sexually transmitted infections and disease screenings (20). Though adolescents are in

support of over-the-counter access, many adults oppose this option for minors.

In the past five years, there has been an expansion in state legislature allowing

pharmacists to prescribe hormonal contraceptives (4). This innovation allows for

increased access to contraceptive services with pharmacists counseling, screening for

contraindications, and prescribing an appropriate hormonal contraceptive method for use.

This method is also not supported for adolescent access, as adolescents tend to over-

report contraindications without official diagnosis (4). There are many barriers to the

enactment of this innovation. They include a lack of standard protocols, a negative

impact on pharmacy workflow, and patient materials not suitable for minors (21).

Additional threats include the requirement for a different skill set compared to a

traditional pharmacist and an inability to provide private counseling due to limited space.

One method to overcome these barriers is the use of collaborative drug therapy

management. This program involves a collaborative agreement between physicians and

pharmacists granting pharmacists professional responsibility for many roles (4). Further

studies involving this method may prove beneficial to increasing access and continuation

of hormonal contraceptive methods.

Laws regarding what services can be accessed through telehealth services also

varies from state to state. Telehealth services have the ability to increase access to

women’s reproductive health and contraceptive services. Women of all ages are able to

safely be screened and consulted by a physician before being prescribed a particular

contraceptive method for use (4). Many companies and health organizations currently

provide telehealth services for prescription hormonal contraceptives. Significant reasons

for promoting telehealth expansion for contraceptive and women’s health services

include ease of online service, inability to get an appointment with a provider, and a need

for confidentiality.

Overall, women face many obstacles in obtaining affordable and accessible

contraception for women’s reproductive and self-care needs. Structural barriers, coverage

barriers, and political barriers limit women’s ability to have power and autonomy over

their health achieving future goals. Reducing the barriers to affordable and accessible

contraceptive services while also making strides to address the gaps in research has the

ability to improve women’s confidence in initiating and continuing the use of hormonal

contraceptives for reproductive and self-care maintenance.

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