TxPEP Researchers Give Testimony in Texas Senate
Fri, February 28, 2014
On February 20, 2014, TxPEP researchers Abigail Aiken, Kristine Hopkins, Joe Potter, and Amanda Stevenson provided evidenced-based testimony that included suggestions to improve the provision of contraception in Texas. The researchers emphasized the benefits of making long-acting reversible contraception (LARC) more easily accessible to low-income women in Texas.
Evidence-based Recommendations to Improve the Provision of Contraception in Texas
Testimony prepared for the Senate Health and Human Services Committee, February 20, 2014
[document updated March 28, 2014]
I. Texas Has an Opportunity to Improve Its Women’s Health Programs by Using Evidence-Based Practices
- Texas has a unique opportunity to lead the nation in providing high quality family planning services to low income women by designing its family planning program funding streams based on evidence of best practices. Both the Texas Women’s Health Program and the Expanded Primary Healthcare program are designed and administered by the State without Federal requirements. This means that Texas can follow the latest scientific recommendations for providing access to the most effective methods of contraception.
II. Research Findings Relevant to the Provision of Family Planning Services in Texas
Long Acting and Reversible Contraceptive Methods (LARC)
Background: Long-acting reversible methods of contraception (LARC) include hormonal and non-hormonal IUDs (such as Mirena and ParaGard) and contraceptive implants (such as Nexplanon). LARC methods are the most effective reversible methods of contraception. Studies show that when LARC methods are offered for free or low-cost as first-line methods (discussed first among all the methods of contraception), LARC use and satisfaction are high. Professional associations such as the American College of Obstetricians and Gynecologists recommend LARC as first line contraceptive methods that are appropriate for most women (ACOG 2009; ACOG 2012).
- Increased use of long-acting reversible methods of contraception (LARC) has been shown to decrease repeat abortions and unintended pregnancy (Peipert et al. 2012)
- Most experts agree that recent reductions in unintended pregnancy rates nationwide are due to increased LARC use, however there is great variation across states in LARC uptake (White et al. 2013).
- Texas’ long-term record of declining unintended pregnancy and teen pregnancy rates is likely due, at least in part, to greater use of effective methods of contraception like the pill. These rates could be further reduced with expanded access to LARC methods.
LARC Provision Can be Very Low among Primary Healthcare Providers
Background: Specialized family planning providers tend to provide a wider variety of contraceptive methods (including LARC methods) compared to primary healthcare providers. Legislation in 2011 that placed specialized family planning providers in the lowest funding tier, as well as enforcement of the affiliate ban, reduced Texas women’s access to these providers (White et al. 2013). Texas state family planning programs therefore now rely on primary healthcare providers to deliver the majority of state-subsidized family planning services.
- Recent research and our own interviews with Texas providers show that primary healthcare providers do not always offer LARC (Beeson et al. 2014, Wood et al. 2014, White et al. 2013).
- Primary healthcare providers may fail to offer LARC methods because they lack appropriate training, are not up to date on guidelines and evidence-based protocols and/or because LARC methods are costly to keep in stock (Vaaler et al. 2012; Dehlendorf et al. 2010; ACOG 2009; ACOG 2012)
- Making funding conditional upon widely offering the full range of contraceptive methods increases the provision of LARC methods among primary healthcare providers (Wood 2014).
- EPHC does not currently require providers to provide LARC methods.
High Quality Contraceptive Counseling is Important to Increasing Uptake of LARC
Background: High quality contraceptive counseling includes devoting adequate time to discussing a wide range of contraceptive options, addressing women’s questions and concerns, and highlighting LARCs as the most effective options.
- Recent research has demonstrated that high-quality LARC-supportive contraceptive counseling increases the use of LARC methods (Secura et al 2010; Peipert et al. 2012).
Our research in Austin and El Paso has demonstrated that the frequency of prenatal contraceptive counseling is very low. Rates of postpartum counseling are higher, but even among women who did report counseling, discussion of LARC, sterilization and vasectomy was infrequent, and very few women reported feeling encouraged to use these highly effective methods.
There is Unmet Demand for LARC in Texas
- Our study of women in Austin and El Paso has found that there is substantial demand for LARC methods (particularly among postpartum women), but that women have trouble accessing them. (Potter et al. 2013)
- Our survey of family planning providers also found that providers responded to the 2011 funding cuts by decreasing the availability of LARC methods (which have high upfront costs).
There is Unmet Demand for Female and Male Sterilization in Texas
- There is unmet demand for postpartum female sterilization in Texas (Potter et al. 2012)
- There is huge variation across hospitals in rates of postpartum tubal ligation (Potter et al. 2013)
- Our interviews with providers, men, and women show an unmet demand for vasectomy in Texas.
Covering the Costs of LARC and Sterilization Would Produce Medicaid Cost Savings
- In our longitudinal study of postpartum women in Austin, 70% of women who had an unintended pregnancy said they wanted but could not access LARC or sterilization in the postpartum period.
- The costs of providing these women with highly effective contraception would be dwarfed by the savings realized by postponing or preventing these births.
III. Specific Recommendations
To support Texas’ continued improvement in its unintended pregnancy and teen pregnancy rates, and to reduce the need for abortion care in our state, we suggest increasing access to long-acting reversible contraceptive methods in three ways.
1. To increase access to LARC methods for all women served by state-funded programs, we recommend that:
A. Require providers that receive state funds for provision of family planning services to have LARC methods available to their patients. For example, providers receiving EPHC or DSHS FP funds should have sufficient stock-on-hand to provide LARC methods to their projected family planning patients. Similarly, the state could require that TWHP providers who serve more than a certain number of women per year (e.g., >50) should have sufficient stock-on-hand to provide LARC methods to their patients.
B. Require providers that receive state funds for provision of family planning services and TWHP providers that serve larger numbers of women to have at least one provider on staff at each clinic site who is trained in LARC insertion.
C. Require all providers receiving EPHC or DSHS FP funds, and TWHP providers who serve larger numbers of women to attend contraceptive counseling training to support their provision of LARC methods.
2. To increase access to female sterilization and LARC postpartum, we make the following recommendations:
A. Require high-quality contraceptive counseling training, which includes discussion of LARC and sterilization methods, for all prenatal providers that serve large numbers of Medicaid patients.
B. Require that all hospitals that are reimbursed for more than a certain number of Medicaid-paid deliveries per year (e.g., >50) stock LARC devices for postpartum insertion.
C. Allow Medicaid (including TP30 and Medicaid for pregnant women) to pay for postpartum LARC insertions outside of the global fee for delivery.
D. Allow Emergency Medicaid to pay for contraceptive methods, including LARC and sterilization procedures, during the same period as covered by Medicaid for pregnant women (60 days postpartum).
3. To increase access to male sterilization, we recommend the following:
A. Increase vasectomy reimbursement rates for EPHC and DSHS FP programs to an amount that is closer to that which urologists charge for the procedure.
B. Allocate dedicated funding streams for vasectomy services (e.g., expand EPHC or DSHS FP funds) so that providers do not have to choose between providing services to women and providing services to men.
C. Design a vasectomy outreach campaign to educate Texas men and women about the availability of vasectomy via newly allocated family planning money suggested above.