Fresh ideas, workarounds during pandemic can increase access to contraception

Introduction

Although the coronavirus disease 2019 (COVID-19) pandemic has altered many health care practices, it has not changed the need for safe, efficient, and equitable contraception. In the United States, 45% of all pregnancies are unintended, and the rates of unintended pregnancy are highest in individuals with low income and those who are non-Hispanic Black or African American, populations known for reduced access to health care services.¹

Because in-person contact with the health care system has been limited during the pandemic, ob/gyns should implement or expand upon methods to increase access to contraception. These strategies include same-day and immediate postpartum long-acting reversible contraception (LARC) initiation, home delivery of contraception, and virtual screening for self-start and/or administered contraceptives. Other items for ob/gyns to consider include accessible contraception discontinuation and the safety of contraceptive options for patients with COVID-19.

Contraception and Telehealth

As the pandemic evolved, health care professionals had to pivot rapidly from in-person to remote models of care; 2020 saw the largest expansion of virtual health care (telehealth) services since the system’s inception.² Providing health care remotely is not without its challenges, particularly in the field of obstetrics and gynecology, but is feasible and can be a valuable tool in reaching patients efficiently and effectively when it is not safe for them to be seen in person.

In addition, telehealth has been embraced and supported by national health care organizations.³ Telehealth appointments have a high show rate and high patient and provider satisfaction.^{4, 5} When providing virtual health care services, billing and coding will vary. If a patient is contacted via telephone only (no video), billing and coding will be based on time spent on the phone. If a patient is contacted via synchronous video, meaning that the patient encounter is live rather than viewing a prerecorded video of the patient, billing and coding will be at the same level as an in-person visit (Table).

During the pandemic, Medicare lifted its regulations on the provision of telehealth.⁶ Any qualified health care professional, including physicians and advanced-practice clinicians, can provide and bill for telehealth services. All clinical notes must include documentation that the patient agreed to conduct the visit virtually. Additionally, virtual visits cannot address the same problem as an in-person E/M service that occurred within the previous 7 days or lead to a visit with an E/M code in the following 24 hours. For example, if you perform a telehealth appointment for a patient seeking contraception you must see that patient more than 24 hours later to capture billing for both visits.

With the adjunct of a home pregnancy test with or without emergency contraception, many contraceptive methods can be initiated or continued without an in-person visit. Health care professionals can utilize telehealth as a screening visit to elicit the patient’s preferences for birth control and assess eligibility. If an in-person visit is deemed necessary—for example, the patient desires a contraceptive implant or intrauterine device (IUD)—the visit should be provided within a reasonable time frame. Many forms of contraception can be provided virtually, including pills, patches, rings, and self-administered subcutaneous medroxyprogesterone acetate. A simple medical screening can be conducted virtually to ensure eligibility. For estrogen-containing formulations, a blood pressure measurement within the last year is sufficient; if the patient has no documented blood pressure, a prescription for a home blood pressure monitoring kit can be provided with the prescription for contraception.^7,8

Similarly, prescriptions for contraception should not be withheld due to lack of screening for cervical cancer or sexually transmitted infection (STI).⁸ Additionally, some pharmacists may be able to administer intramuscular medroxyprogesterone acetate. Although luteal phase pregnancies are unlikely, a shared decision-making approach is recommended when providing quick-start contraception virtually.⁹ The Centers for Disease Control and Prevention provides a mobile application with guidelines on how to be reasonably certain a patient is not pregnant, when to start contraception, and when to use backup contraception.¹⁰

Mail-Order Pharmacies and Mobile Apps

Similar to the dramatic expansion of telehealth during the pandemic, mail-order pharmacies, often through mobile applications, have increased in popularity. Patients provide medical history via questionnaire through an online portal and select a contraceptive method after reading educational information. All services will ask for a blood pressure reading for any combined hormonal methods, as per US Medical Eligibility Criteria.¹⁰

A physician or advanced care practitioner then reviews the medical history before sending a prescription to a mail-order pharmacy. In certain states, a video telehealth visit also may be required. Turnaround time ranges from next-day delivery up to 2 weeks. Contraceptive options include pill, patch, ring, and self-administered subcutaneous medroxyprogesterone acetate.

Several companies also offer services such as emergency contraception including levonorgestrel or ulipristal acetate, STI testing, urinary tract infection and migraine treatments, HIV preexposure prophylaxis, and HPV screening. It should be emphasized, however, that cervical cancer and STI screenings are not required prior to initiating these methods. Depending on their insurance, patients can get up to 12 months of contraception delivered at a time, with automatic refills available. Many of these apps also accept patients without insurance. However, not all companies operate in all 50 states, since these services are relatively new and implementation must follow state laws governing mail delivery of medication.

Although not much data exist on the provision of contraception via mail-order pharmacies, the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians, the American Medical Association, and the American Public Health Association support this access to hormonal contraception.¹¹ In addition, a 2006 study found that patients’ self-assessment and provider assessment of contraindications to contraception agreed in more than 95% of cases.¹²

The pandemic and LARC access

Maintaining access to the most effective methods of contraception, such as IUDs and contraceptive implants, involves in-person contact. Luckily, there are a wealth of existing data and society recommendations supporting same-day initiation of LARC as a safe practice that leads to increased LARC uptake and decreased rates of unintended pregnancy.¹³ In order to decrease in-person contact, contraceptive options counseling can be done via telehealth, with the patient presenting for an in-person appointment only for the insertion of the device. IUDs and implants can be inserted at any point during the menstrual cycle as long as pregnancy can be reasonably excluded.¹⁴

Postpartum contraceptive access during the pandemic

For patients who are newly postpartum during the pandemic, contraceptive counseling can be done either as part of antenatal care or during their admission for delivery. For short-acting methods such as pills, a prescription can be placed as part of a patient’s hospital discharge, ensuring they will have access when they need it, regardless of timing of the postpartum visit.

Additionally, immediate postpartum IUDs and implants, placed after delivery but prior to discharge from the hospital, are evidence-based and safe methods of LARC initiation.¹³ These approaches allow women to initiate their preferred postpartum method of contraception without requiring an in-person postpartum visit. Immediate postpartum LARC initiation also has been shown to increase rates of LARC uptake and decrease rates of unintended and rapid repeat pregnancies.¹⁵

LARC discontinuation

From a reproductive justice standpoint, efforts to provide seamless, reduced contact contraception during the pandemic must be balanced with a patient’s right to on-demand access to discontinuation of contraception, particularly of LARC.^16,17,18 This comes within the context of a history in the United States of reproductive coercion and sterilization of individuals of color, low-income individuals, and other vulnerable populations.¹⁹

As part of this, self-removal of IUDs is growing in popularity. Likely exacerbated by the pandemic, patients have cited an inability to obtain an appointment for IUD removal and inappropriate cost for the removal as reasons they attempt to remove the devices themselves.²⁰ In a study of women seeking IUD removal, a majority (59%) were willing to try self-removal after receiving instructions from their health care provider, and of those who attempted it, 1 in 5 were successful.²¹ Counseling by providers at the time of insertion about the potential of self-removal and/or telehealth counseling prior to attempting removal can help alleviate both patient and provider concerns.²²

For patients who are not interested in or are unsuccessful with self-removal, in-person appointments for IUD removal should be made available. Furthermore, these appointments should be made available for implant users, for whom self-removal is not an option.

As with LARC placement, counseling can occur via telehealth, and the patient then can present for a focused in-person appointment for removal. When counseling patients on LARC removal, providers should consider extended use studies of various LARC methods beyond FDA-approved duration of use.13 Notably, the levonorgestrel-20 IUD has been shown to be effective for 7 years, the copper IUD up to 12 years, and the contraceptive implant up to 5 years.

Sterilization during the COVID-19 pandemic

During the pandemic, many hospital systems and providers have postponed or canceled elective or nonemergent surgical procedures. There are no existing data on what effect this may have had on access to sterilization procedures. Previous data have demonstrated that unfulfilled sterilization requests among postpartum women lead to high rates of unintended pregnancy; 47% were pregnant by 12 months postpartum.²³ ACOG encourages continued provision of sterilization procedures when possible during the pandemic and discussions with patients to identify bridge methods of contraception when sterilization is not possible. Deciding to proceed with nonemergent surgery during the pandemic should be based on local and institutional policies, availability of local health care resources—including staffing and personal protective equipment (PPE)—and the prevalence of COVID-19 in the region.⁸

COVID-19 infection and contraceptive use

There are no published data on the safety profiles of contraceptive methods in patients with COVID-19, particularly the hormonal methods. However, there are studies documenting coagulation factor changes leading to a hypercoagulable state with COVID-19, including evidence of increased risk of thromboembolism with worsening severity of disease.²⁴ The CDC has indicated that the risk of combined hormonal contraceptives (CHCs) and other estrogen-containing methods, particularly for cardiovascular and thromboembolic events, outweigh the benefits in patients with factors predisposing them for deep vein thrombosis (DVT) or pulmonary embolism (PE).¹⁰ These factors include current or prior DVT/PE, being within the 6-week postpartum period, hypertension, smoking, and known hypercoagulation disorder. By extension, shared decision-making should be employed when counseling patients with COVID-19 (particularly hospitalized patients or patients with severe disease) on CHCs and estrogen-containing methods.⁷ On the other hand, progestin-containing or hormone-free methods, including progesterone-only pills, progestin-containing or copper IUDs, and the contraceptive implant, have been shown to have minimal risk for coagulability and should be unrestricted.¹⁰

Conclusion

Telehealth is critical for providing a means of counseling patients on contraception and screening to determine appropriateness of contraceptive initiation, continuation, and removal. If a patient still requires an in-person visit after a telehealth visit, particularly for LARC placement or removal, appointments should be made available within a reasonable time frame. For the postpartum patient, care should be taken to organize contraception prior to discharge from hospitalization for delivery. For patients desiring sterilization, bridge methods should be offered if there are restrictions on elective surgeries. The pandemic has led to ob/gyns implementing new and different strategies to maintain access to care during this unprecedented time in history, and many are now established as best practices. Indeed, even beyond this pandemic, approaches that reduce the need for patients to interact in person with the health care system may be instrumental in lifting barriers to contraception for the most marginalized populations.

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References

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