We know that many barriers to accessing safe, equitable, and effective contraception exist at individual, institutional, and societal levels. These include things such as lack of insurance, inability to get a timely appointment, difficulty taking time off from work or childcare, and required (but not evidence-based) pelvic exams or other pre-requisites. Unfortunately, the COVID-19 pandemic is heightening many of these existing barriers as unemployment rises, clinics limit or eliminate in-person visits, and people are juggling additional responsibilities on top of already busy schedules. This puts people at higher risk for unintended and unwanted pregnancies and has the potential to worsen existing inequities.
As the number of clinics within our primary care network (at Cambridge Health Alliance) conducting in-person visits decreased during the early days of the pandemic, it quickly became apparent that access to patients’ contraceptive-of-choice would become more difficult. For example, one patient presented to our clinic for abortion care after becoming pregnant while waiting for placement of a postpartum IUD (her original appointment was canceled during early stages of the pandemic). Other patients have had to use methods of contraception they do not prefer as they are put on indefinite hold for in-person visits, and some patients may not have access to contraception at all (i.e. if they have contraindications to options that may be available via telehealth). This may increase the rate of unintended pregnancies, particularly since studies show the most effective method of contraception is the method that each individual prefers to use.
Although COVID-19 has certainly increased some barriers to contraception, it has also provided us with an opportunity to step back and re-evaluate how we approach contraceptive care. Namely, do we actually need in-person visits for all types of contraceptive management? This pandemic has demonstrated that the great majority of contraceptive initiation, management, and discontinuation can be managed via telehealth or perhaps without clinician interaction at all. We can safely evaluate a patient’s pregnancy status (by history and/or home urine pregnancy test), screen for contraindications to methods (e.g. by utilizing home blood pressure cuffs), and manage adverse effects without in-person visits. Evidence-based practical resources like the CDC Selected Practice Recommendations for Contraceptive Use can be used to implement telehealth workflows to determine which tests are needed before initiation of contraceptive methods, how to be reasonably certain that a person is not pregnant, and when to start using specific methods.
Further, safe and effective emergency contraception is already available over-the-counter. Beyond oral contraceptives, a subcutaneous version of depo-provera is available for self-administration at home. Data shows that self-removal of IUDs is safe and acceptable. Strong evidence also supports the efficacy of extended use of the implant, copper IUD, and levonorgestrel IUD to two years beyond their current FDA labeling. Discussion of this evidence with patients who fall into the extended use timeframe allows them to make an informed decision about the safety of postponing removal during the pandemic.
For patients who desire an in-person visit for insertion or removal of an IUD or implant, we must maintain access to these necessary appointments. Patients desiring long-acting reversible contraceptive (LARC) insertion and/or removal can be counseled on the risks, benefits, and what to expect during the procedure via telehealth visit prior to the in-person appointment. To limit time in the office, providers should consider obtaining verbal consent over the phone or using electronic signature technology instead of written consents.
While it may seem more important to maintain access for patients desiring contraceptive initiation, we argue that it is equally important to maintain access via telehealth or in-person visits for patients desiring to stop their respective method of contraception. Limiting or denying access to in-person visits for implant or IUD removal during the COVID pandemic can perpetuate reproductive coercion at the health systems level and exacerbate already existing health inequities. Among other things, we know patients already face financial barriers to LARC removal (LARC placement is typically covered by insurance under the ACA expansion but removal is billed separately and may not be covered), as well as resistance from providers if they are perceived as desiring LARC removal “too early” or “for the wrong reasons.” Preserving patients’ ability to access LARC removal despite the COVID pandemic is essential to maintaining equitable and patient-centered care.
As we navigate provision of high-quality contraceptive care, we can certainly learn from the COVID pandemic about how patients access and utilize contraception. Systems that allow flexibility in navigating safe access to contraception, as well as increased control over preferred contraceptive method, have the power to improve quality of care and further address reproductive health inequities.
**Feature photo obtained with standard license on Shutterstock.
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Natalie Krumdieck, MD, is a Family Medicine Physician at Cambridge Health Alliance and the Reproductive Health & Advocacy Fellow at Tufts University Family Medicine Residency Program.
Honor MacNaughton, MD, is the Associate Program Director of the Tufts University Family Medicine Residency Program, the Medical Director of the Reproductive Health Clinic at Cambridge Health Alliance, and an Associate Professor of Family Medicine at Tufts University School of Medicine. She is active with the Reproductive Health Access Project (RHAP) as the National Director of the Reproductive Health Care and Advocacy Fellowship. Her areas of interest include medical education and the integration of full-spectrum reproductive health care into primary care settings.
