U.S. women are interested in receiving contraceptive methods—including long-acting reversible methods (the IUD and the implant)—as part of a visit to an abortion care facility, but insurance and high cost may be barriers to integrating abortion and contraceptive services. In a survey of abortion clinic patients, 67% of women wanted to leave their appointment with a contraceptive method; 37% were interested in using the IUD in the future, and 27% were interested in the implant.1 And in a survey of administrators of abortion facilities, four out of five respondents perceived insurance issues and high cost as barriers to integrating contraceptive and abortion services.2 Greater proportions of facilities that accepted insurance for contraceptive services than of those that did not offered the IUD (69% vs. 37%), the implant (38% vs. 4%) and immediate postabortion insertion of the IUD or implant (38% vs. 21%).
Patients’ Attitudes
To investigate women’s attitudes toward receiving contraceptive services as part of abortion care, between March and May 2010, researchers surveyed a sample of 542 patients at five abortion clinics selected from all U.S. facilities that had performed at least 1,000 abortions in 2005. Multivariate analyses examined associations between women’s characteristics and both their desire to receive a contraceptive method during their abortion appointment and their interest in using a long-acting method.
About half of clinic patients were younger than 25, were white, and were never-married and noncohabiting. Sixty-three percent had an income below 199% of poverty. Some 31% of women reported having no health insurance, 37% had private insurance, 28% were covered under Medicaid and 4% had other insurance. Half of women had had at least one previous abortion. Sixty-eight percent had heard of one or both long-acting contraceptive methods, but only 5% and 1% had previously used the IUD and implant, respectively. The most common methods used by women in the past were the condom and the pill (79% and 70%, respectively).
The largest proportion of patients (52%) cited the abortion clinic as their preferred setting for discussing contraceptive information. Sixty-seven percent wanted to leave the clinic that day with a contraceptive method, but only 44% expected to do so; 37% expected to receive information on pregnancy prevention methods, and 5% expected a referral to another health care provider. The condom and the pill were the methods most women were interested in using after their abortion (63% and 59%, respectively); 37% were interested in using the IUD, and 27% the implant.
In multivariate analyses, women covered by Medicaid had greater odds than those with private insurance, and those who had ever used the pill had greater odds than those who had not, of expecting to leave the abortion clinic with a contraceptive method (odds ratios, 2.0 and 2.8, respectively). Women who had heard of the IUD or implant and those who had had a previous abortion had elevated odds of being interested in future use of a long-acting contraceptive method (2.1 and 2.3, respectively); compared with whites, black women were less likely, and women of other ethnicities were more likely, to report interest in using a long-acting method (0.5 and 5.8, respectively).
The researchers comment that "for some women, and particularly those without health insurance, the abortion clinic may provide one of their few contacts with the health care system and, in turn, opportunities to access contraception." While acknowledging that their sample was not nationally representative, they conclude that their study still "provides evidence that many women are interested in learning about and obtaining contraceptive methods, including long-acting methods, in the abortion care setting."
Provider-Perceived Barriers
As part of a study to identify barriers that abortion providers experience in integrating contraceptive and abortion services, researchers randomly selected a nationally representative sample of 251 U.S. nonhospital facilities from all those that provided at least 400 abortions per year. Between May and September 2009, administrators at 173 selected facilities completed a survey about the availability of specific contraceptive methods at their facility and their perception of factors that might interfere with the integration of contraceptive and abortion services there. Bivariate analyses examined associations between perceived and logistical barriers and the availability of contraceptive methods.
According to administrators, abortion facilities generally offered a range of contraceptive methods, either as free samples or at cost: Ninety percent provided the pill, 80% the injectable, 71% the vaginal ring, 59% the IUD, 51% the patch and 28% the implant. Four out of five administrators reported that insurance issues, patient-related issues (e.g., patients’ feeling anxious about the abortion procedure) and high cost were barriers to integrating contraceptive and abortion services; two out of five reported facility-level issues (e.g., clinicians’ needing more training or experience for some methods) as barriers to service integration.
Perceived barriers were associated with the availability of certain methods and with certain contraceptive provision strategies. Greater proportions of facilities at which insurance issues were perceived as a barrier than of those at which they were not offered the vaginal ring (75% vs. 54%) and the patch (55% vs. 32%) on-site. A larger proportion of facilities at which patient-related issues were a perceived barrier than of those at which they were not provided the injectable (83% vs. 67%), whereas smaller proportions of facilities at which high cost was a perceived barrier than of those at which it was not offered the patch (46% vs. 71%) and immediate postabortion insertion of an IUD or implant (30% vs. 50%).
Facilities that accepted insurance for contraceptive services were more likely than others to offer long-acting contraceptive methods on-site. Among facilities that accepted insurance, 69% provided the IUD, and 38% the implant; the proportions among facilities that did not accept insurance were 37% and 4%, respectively. In addition, a greater proportion of facilities that accepted insurance than of those that did not offered immediate post-abortion insertion of an IUD or implant (38% vs. 21%). Provision of long-acting methods was positively associated with insurance acceptance among specialized abortion clinics (i.e., facilities at which at least half of services were related to abortion), but not among broader based facilities. Providers in states that allow Medicaid to cover abortion services were more likely than those in other states to accept public or private insurance for contraceptive services.
Discussing their study’s limitations, the authors note that administrators’ responses may have been subject to social desirability bias and that their perceptions of patient-related barriers may not reflect those of the patients themselves. They conclude that long-acting reversible contraceptive methods "require less user involvement and less frequent contact with clinicians and are thus ideally suited for broader integration into the abortion care setting. However, this can happen only if cost and insurance barriers are removed."—J. Rosenberg