issue brief LONG-ACTING REVERSIBLE CONTRACEPTIVES A Survey of Mississippi Health Care Providers PUBLISHED OCTOBER 2018 Women in Mississippi experience high rates of unintended pregnancy, which can be associated with the use of less effective methods of contraception. In an effort to better understand the role of health care providers in contraceptive More than half of Mississippi births access, the Center for Mississippi Health Policy engaged researchers at the result from unintended pregnancy. Social Science Research Center at Mississippi State University to survey Improving access to long-acting reversible medical doctors and nurse practitioners regarding their experience and opinions contraception has been part of successful strategic initiatives undertaken in other about the most effective family planning methods. states to reduce rates of unintended pregnancy. For more in-depth exploration of unintended pregnancy and LARCs, Women who seek family planning services at publicly-funded clinics in please refer to the Unintended Pregnancy in Mississippi Issue Brief and Chartbook at the Mississippi are the least likely in the country to use the most effective reversible Center’s website. contraceptives. As health care providers are a key factor in a woman’s access to effective birth control, obstetrician-gynecologists (ob-gyn’s), family physicians, and nurse practitioners in Mississippi were recently surveyed about their knowledge, opinions and practice behaviors regarding long-acting reversible contraceptives CONTRACEPTIVE METHODS BY (LARCs), the most effective, reversible methods of birth control. EFFECTIVENESS More than 90 percent of ob-gyn’s included in this survey reported receiving training Most Effective Reversible for counseling, insertion, and removal of LARCs, while just over half of family Methods practice doctors and approximately 30 percent of nurse practitioners reported also called Long-Acting Reversible Contraceptives (LARCs): receiving training on LARC insertion and removal. As Figure 1 shows, ob-gyn’s Implant report high numbers of insertions of LARCs, while family practice physicians and IUD nurse practitioners are much more likely to refer women to other providers for Moderately Effective Methods: insertions. Injectable Contraception Vaginal Ring FIGURE 1. APPROACH TO LARCS BY PROVIDER TYPE Contraceptive Patch Oral Pill Do Not Family Practice 7.4% Diaphragm Recommend Nurse Practitioner 3.8% Less Effective Methods: LARCs Ob-gyn 0.0% Male and Female Condoms Refer out for Family Practice 52.9% Sponge LARCs Withdrawal Nurse Practitioner 70.2% Fertility-based Awareness Ob-gyn 2.8% Spermicide Insert LARCs Family Practice 14.7% Source: Centers for Disease Control and Nurse Practitioner 9.1% Prevention. (2011). Ob-gyn 75.0% Source: Social Science Research Center, Mississippi State University. (2018). Note: The relationship between provider type and approach to LARCs is statistically significant, p<0.000. Nationally, 70 percent of women 18-44 rely on a family practice doctor as their regular source of care, while 14 percent rely on an ob-gyn, and 10 percent rely on a nurse practitioner. Each of these clinicians is trained to provide basic family planning and reproductive health services, however, ob-gyn’s, due to more specialized training, are more likely to provide the full complement of contraceptive options. 1 of 4 Center for Mississippi Health Policy � Issue Brief: Long-Acting Reversible Contraceptives- A Survey of Mississippi Providers � OCTOBER 2018 Factors Associated with LARC Provision DRIVE TIME TO OB-GYNS Because the providers most likely to be a woman’s regular source of primary and preventive care in Mississippi may be less likely to offer a full complement of family planning options, provider availability may be a key factor driving access to LARCs. Across the country, ob-gyn’s are in short supply and are projected to be in increasingly shorter supply as older physicians retire faster than newly trained doctors complete their training. This is especially true for Mississippi where the provider to patient ratio of 7.5 providers per 10,000 women ages 15-44 is one of the lowest rates in the United States. As of 2014, just 429 active ob-gyn’s served the state, practicing in just 36 of 82 counties and clustering in urban areas and around facilities with labor and delivery units. Women in the majority of counties in Mississippi face at least an hour-long drive for prenatal, delivery, and post-partum care, as well as family planning if they 15 minutes want to see an ob-gyn. Women without means to travel may be limited to publicly 30 minutes funded clinics which are less likely to be staffed by ob-gyn’s. 60 minutes or more Source: American College of Obstetricians & Provider training impacts patients’ use of birth control methods Gynecologists. (2014) Oral birth control pills are the most frequently used contraceptive method among patients of all providers responding to the survey (47 percent). Providers estimate PUBLICLY-FUNDED CLINICS ACROSS that 15 percent use injectable hormonal contraception (Depo Provera), and 16 MISSISSIPPI percent use LARCs (IUDs and Implants). Family practice physicians and nurse practitioners, who are more readily available throughout the state and in rural areas, provide family planning and reproductive health services to many women; however many report a lack of training for LARC counseling or inserting and removing LARCs. FIGURE 2. LARC TRAINING REPORTED BY PROVIDER TYPE FAMILY NURSE OB-GYNS PRACTICE PRACTITIONERS I have sufficient experience in inserting LARCs* 97.3 29.0 22.0 I have sufficient information to counsel patients about LARCs* 100.0 80.0 68.5 Health Department I was formally trained in LARC counseling* 86.3 49.3 40.6 FQHCs (main sites) I was formally trained in LARC insertion* 97.3 54.8 29.2 I was formally trained in LARC removal* 94.5 53.4 32.4 At time of publication, 5 medical doctors and 8 nurse practitioners serve all county health I have sufficient experience in removing LARCs* 98.6 45.7 29.5 departments providing family planning services. Mississippi’s 20 FQHC grantees are staffed by 16 ob-gyn’s, 35 family practice physicians, and 180 Source: Pellegrine, I. & Southward, L. (2018). Note: *Statistical significance: p<0.001. nurse practitioners. Medicaid medical claims data show that female beneficiaries 15-44 use Despite a wide geographic distribution, few of these publicly-funded clinics provide ready access moderately effective methods more than the most effective methods of birth to the full range of contraceptive methods. control, but the degree differs by the type of provider rendering the service. Also, contraceptive services are not necessarily Claims data for the period 2013-2017 show that twice as many patients of ob-gyn’s available on a regular basis and may have waiting periods for some services up to six weeks. received LARCs as received Depo Provera injections. On the other hand, four times as many patients of family practice physicians, nurse practitioners, and other Source: Health Resources and Services Administration. 2017 Health Center Program Grantee Data. (2017). mid-level providers received Depo Provera injections as LARCs. (The oral pill is Mississippi State Department of Health. (2018). not included in this analysis due to industry billing practices.) 2 of 4 Center for Mississippi Health Policy � Issue Brief: Long-Acting Reversible Contraceptives- A Survey of Mississippi Providers � OCTOBER 2018 Provider Practice Patterns and Opinions Provider opinion on the appropriateness of LARCs can vary for different patient populations. Figure 3 demonstrates the wide variation in reported provider opinion. ACOG COMMITTEE OPINION NO 10. Ob-gyn’s were more likely to recommend LARCs for patients regardless of age, The American College of Obstetricians and Gynecologists has formally recommended that number of sexual partners, or prior pregnancies. providers discuss LARCs with women of all reproductive ages including adolescents. FIGURE 3. LARC APPROPRIATENESS FOR VARIOUS PATIENT TYPES ACCORDING TO PROVIDER TYPE A patient who has never had a child*** A patient who has at least one child** A patient with one exclusive sexual partner* A patient with multiple sex partners*** A patient planning to have children at some point in the future*** A patient who has had an ectopic pregnancy*** A patient who has had an abortion*** A patient under 18 years of age*** A patient between 19 and 25 years of age*** A patient between 25 and 39 years of age*** A patient 40 year of age or older*** 20 30 40 50 60 70 80 90 100 Nurse Practitioner Family Practice Ob-gyn Source: Pellegrine, I. & Southward, L. (2018). Note: Statistical significance: *p<0.05; **p<0.01; ***p<0.001. Health care providers are uniquely positioned to identify barriers to care within the health care system and, to some degree, within their patients’ lives. When asked about improving access to LARCs for their patient population, the top three areas for improvement suggested by all provider types were the following: Improved access to contraception providers is one of the top three most important factors for improving patient access to contraception according to family Cost of care, including patient insurance coverage, out of pocket costs to practice physicians and nurse practitioners surveyed. patients, and low reimbursement for providers Patient education about contraceptives Access to contraception providers, including public clinics and trained clinician workforce REPORTED ABILITY TO PROVIDE SAME-DAY Practice conditions and LARC provision are strongly associated. Providers who LARC INSERTIONS BY PROVIDER TYPE perceived that conditions in their practice support offering LARC services reported 80% higher numbers of actual LARC insertions in the past 12 months. Favorable 60% practice conditions include the following: 61% 40% Acceptable reimbursement from private and public payors Adequate stock of LARC devices and reasonable cost to purchase them 20% 16% Sufficient staff and staff time to offer the service 0% 7% OB FP NP Source: Social Science Research Center, MSU. (2018). Ob-gyn’s were significantly more likely to agree that their practice setting reflected these favorable conditions. 3 of 4 Center for Mississippi Health Policy � Issue Brief: Long-Acting Reversible Contraceptives- A Survey of Mississippi Providers � OCTOBER 2018 Summary Providers with the most training and experience in LARC provision are in short DELAWARE CONTRACEPTIVE ACCESS NOW (CAN) Delaware, which had the highest unintended supply and potentially out of reach for many women in our state. Data from a pregnancy rate in the country in 2010, recently recent survey suggest that if a woman in Mississippi does not have access to focused on provider education and training on an ob-gyn she is less likely to be able to access the most effective birth control LARCs in publicly-funded clinics. Among Delaware Title X family planning clients aged 20 to 39, LARC methods if she wants them. use increased from 13.7 percent to 27.0 percent over 3 years. Provider practice patterns based on attitudes, training, and understanding of COLORADO FAMILY PLANNING INITIATIVE LARC appropriateness have the potential to limit Mississippians’ access to Colorado greatly increased the number of women family planning methods that could meaningfully impact their lives. Seventy using LARCs by reducing the cost of LARCs and percent of family practitioners and nurse practitioners (the most readily available providing patient education. That increase has been linked to a 35 percent decrease in abortion provider types) have reported that they do not insert LARCs. Rather, those who rates, a 40 percent decrease in babies born to recommend LARCs but do not insert the devices refer their patients to other teenage mothers, and a 12 percent decline in pre- provider types who do insert, but who may be long distances away. term births that occured between 2009 and 2014. MISSOURI CHOICE Mississippi is unlikely to have ob-gyn’s locally available to all women across the The Missouri CHOICE project was able to support state and in rural areas. However, a concerted effort will be needed to ensure that the uptake of more effective birth control among Mississippi women have access to providers offering all contraception services. teenagers and young women through more comprehensive counseling on all methods of birth Key components of such an effort include training non-ob-gyn clinicians on control. LARCs were the method of choice among LARCs and educating patient populations about all contraceptive methods. These 75 percent of participants. strategies can impact low utilization of LARCs and reduce unintended pregnancy rates as other states have shown. Sources Lindberg, L., Santelli, J., & Desai, S. (2016). Understanding the decline in adolescent fertility in the United States, 2007-2012. Journal of Adolescent Health, 59(5):577-583. Center for Mississippi Health Policy. (2018). Preventing Unintended Pregnancy in Mississippi. http://www.mshealthpolicy.com/preventing-unintended- pregnancies/ United States Department of Health and Human Services. Office of Population Affairs. (2017). Title X Family Planning Annual Report 2016 National Summary. https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2016-national.pdf March of Dimes. (2015). 2015 Population of women 15-44 in Mississippi. https://www.marchofdimes.org/peristats/Peristats.aspx Pellegrine, I. & Southward, L. (2018). Long-Acting Reversible Contraceptives: Survey Results from Mississippi Health Care Providers. Social Science Research Center. Mississippi State University. Prepared for the Center for Mississippi Health Policy. Mississippi Division of Medicaid. (2018). Medicaid Medical Claims Data (2013-2017). Office of Mississippi Physician Workforce. UMMC. Distribution and Demographics of Mississippi Physician Workforce. (2014). https://public.tableau. com/profile/publish/DistributionandDemographicsoftheMSPhysicianWorkforce/PhysicianWorkforce#!/publish-confirm Health Resources and Services Administration. (2017). 2017 Health Center Program Grantee Data. https://bphc.hrsa.gov/uds/datacenter.aspx?q=d&y ear=2017&state=MS#glist American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 10. https://www.acog.org/Clinical-Guidance-and-Publications/ Committee-Opinions/Committee-on-Adolescent-Health-Care/Counseling-Adolescents-About-Contraception Birgisson, N.E., Zhao, Q., Secura, G.M., Madden, T., and Peipert, J. (2015). Preventing unintended pregnancy: The contraceptive CHOICE project in review. Journal of Women’s Health, 24(5), 349–353. http://doi.org/10.1089/jwh.2015.519 Colorado Department of Public Health and Environment. (2017). Taking the Unintended Out of Pregnancy: Colorado’s Success with Long-Acting Reversible Contraception. https://www.colorado.gov/pacific/sites/default/files/PSD_TitleX3_CFPI-Report.pdf Welti, K. & Manlove, J. (2018). Unintended pregnancy in Delaware: Estimating change after the first two years of an intervention to increase contra- ceptive access. Child Trends. https://www.childtrends.org/wp-content/uploads/2018/03/UnintendedPregnancyDelaware_ChildTrends_March2018.pdf Plaza Building, Suite 700 120 N. Congress Street Jackson, MS 39201 Phone 601.709.2133 Fax 601.709.2134 www.mshealthpolicy.com @mshealthpolicy 4 of 4 Center for Mississippi Health Policy � Issue Brief: Long-Acting Reversible Contraceptives- A Survey of Mississippi Providers � OCTOBER 2018