Yes: Contraceptive Care IS Preventive Care

Dr. Jeanne Conry speaks at the #NotMyBossBusiness rally on the Supreme Court steps on March 25, 2014.

Dr. Jeanne Conry speaks at the #NotMyBossBusiness rally on the Supreme Court steps on March 25.

I had the unique opportunity to stand on the Supreme Court steps this morning and share my experience as an ob-gyn, and the experiences of my patients back home in California, as the Court hears arguments in the Hobby Lobby case. My patients are among the millions of women who need and deserve contraceptive coverage.

I have treated thousands of women in my career and have seen firsthand how birth control and contraceptive counseling have helped them. For some, it helped to avoid an unintended pregnancy. For others, it helped to delay pregnancy until the time was right. For others, it has helped other medical conditions. But they all had one thing in common: Their family planning decisions were personal and their boss was not in the exam room. That is the way it should be, for every woman, every time.

Contraception, like all medical decisions, should be based on an individual woman’s needs and health – and nothing else. Contraceptive care IS preventive care. It enhances health and improves quality of life for women and for their families. By covering contraceptive care, we are making women’s health a priority, and we are investing in FUTURE generations.

Dr. Jeanne Conry with Cecile Richards, President of the Planned Parenthood Federation of America and the Planned Parenthood Action Fund, at the #NotMyBossBusiness rally on March 25, 2014.

Dr. Jeanne Conry with Cecile Richards, President of the Planned Parenthood Federation of America and the Planned Parenthood Action Fund, at the #NotMyBossBusiness rally on March 25.

Access to contraceptive care can make a world of difference to each woman. It improves the health of our nation and helps our health care system work better for all of us. Contraceptive coverage puts birth control within reach for more American women.
I’m proud to lend my voice to this important issue through my remarks this morning at the Supreme Court (#NotMyBossBusiness) and also here:

I’d also like to recognize important contraception and women’s health messages from two of my physician colleagues whose voices made a difference today:

ADMs, CME, and You: Just What the Doctor Ordered

I have almost completed the “sweep” of our fall Annual District Meetings. Once again, I’m impressed with the dedication of my ob–gyn colleagues across the United States. These meetings are proving to be educational, collegial, and administrative. I say ”administrative” because we discuss the “goings on” of each region, including the political factors impacting each of our states, the public health dilemmas we face, and the effect of changing practice patterns. I look forward to these information exchanges and to sharing insights with my colleagues about the forces influencing our practices and our patients.

For me, the educational component of the ADMs has been most exciting. In a time when physicians are increasingly getting their CME online, the ADM courses provide more than just the course information. They provide perspective and insight from the experts in the field in real time. At the District I, III, and IV ADM in Puerto Rico, Jeffrey F. Peipert, MD, PhD, argued for a paradigm shift in our approach to contraception in his presentation about the St. Louis CHOICE Project. With wider use of LARC (long-acting reversible contraception), we can significantly reduce our nation’s high rate of unplanned pregnancies and abortions and start to see healthier pregnancies. Dr. Peipert provided abundant pearls about how easy LARC is to provide to our patients and how it can improve reproductive health outcomes. We can all use this valuable information in our practices.

At the same ADM, Louis J. Guillette, PhD, gave a rousing talk about the impact of the environment on reproductive health. As it turns out, we both did research at the University of Colorado at almost the same time and even shared members of our thesis teams. Who would guess that our paths would cross 35 years later around shared interests? Dr. Guillette’s message: Increase awareness among our patients—without alarming them—about the vast amount of research implicating environmental factors on our health. And, Deborah A. Driscoll, MD, helped to simplify for us the complex world of genetic testing and familial cancers. Thanks to her, genomic microarray-based technologies are now part of our vocabulary.

Increasingly, physicians are earning more of their CME online. The reality is we are all crunched for time and online CME opportunities are valuable options. But online courses don’t allow for that in-person learning that is so often accompanied by practice pearls. Nor do they provide an opportunity for us to have personal, individual conversations with our colleagues which are so important. I hope that you’ll make plans to attend your next ADM…it’s definitely worth your time.

Remember, registration for the 2014 Annual Clinical Meeting in Chicago opens November 5, just a few weeks away!

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ACOG and ACA: Investing in Women’s Health

As many of you know, I started my ACOG presidency announcing 2013 as “The Year of the Woman” because for the first time we, as a nation, are investing in women’s health care with the Affordable Care Act. It is an investment in our future when we provide all women with preconception care, prenatal care, and contraception.

I spent last week in Washington, DC, discussing the impact of environmental chemicals on our reproductive health with our elected officials. And what a week it was! I saw firsthand the dedication of the furloughed employees who were trying to help everyone. I heard the frustration of many DC residents as they faced reduced work hours and uncertainty about what the next day or week will bring.

Amidst all of this chaos, the ACA’s health insurance exchanges opened for business. Yes, there are going to be some difficulties along the road with implementing health care reform, but there will be fewer of them when we work together to make health care changes a success.

I was in the hair salon recently and found out that the women working there had no health coverage. I opened my iPad and showed them how to enroll in Covered California. In no time, they logged in, found affordable benefits, and were singing its praises. These are working women who had gone without coverage because they could not afford it and their small businesses did not provide health benefits. All of these women—some young, some single moms—all shared one uncertainty: What would they do if they became sick? They had not even considered getting preventive health care.

We need our government to open for business, we need to work on our health care delivery system, and we need to remind everyone that women are finally getting what we said is essential all along: Screening for cervical and breast cancer, screening for intimate partner violence and depression, contraception coverage, and prenatal care. Worrying about not being able to afford or even get health insurance because of a pre-existing condition can now be a thing of the past. Losing your health insurance coverage during the course of a difficult disease when you need it the most can also be a worry of the past. What a wonderful year!

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A Positive Step Toward Preventing Unplanned Pregnancy

The recent US recession did more than make us simply tighten our belts. It’s made many families think long and hard about contraception and when to have children. Research has shown that more women are delaying pregnancy since the start of the recession.

Tough economic times have also led to an increased need for publicly funded family planning services, especially among poor women, who are more likely to have an unintended pregnancy than women of higher socioeconomic status. Today, the Guttmacher Institute released some encouraging statistics—researchers found that publicly funded family planning efforts led to 2.2 million fewer unplanned pregnancies in the US in 2010. Guttmacher estimated that if not prevented these pregnancies would have resulted in more than 1 million unplanned births and more than 760,000 abortions. Additionally, the study showed that every dollar spent on contraceptive services yields $5.68 in public health care cost savings.

These new data underscore what women’s health professionals have known all along: that publicly funded family planning services provide an invaluable safety net for reproductive-age women. It’s great news to see these programs make a real difference in preventing unplanned pregnancy and its consequences.

ACOG has long supported the expansion of the Title X Family Planning program—the nation’s only family planning program dedicated to serving low-income and uninsured individuals regardless of their ability to pay. We will continue to advocate on behalf of the nearly 9 million women who use publicly funded services to ensure that all women—no matter their income—have access to the reproductive health services they need.

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Time Flies When You’re Having Fun

What a ride this past year has been! As I wind down my time as ACOG president, I’m proud of our accomplishments—we remained a strong and vocal supporter of women’s reproductive rights, made strides in standardization of care and patient safety, and moved forward in communication and technology, including the introduction of the new ACOG app for ob-gyns.

Two main themes during my presidential year have been the essentialness of contraceptive access for all women and the importance of having women in leadership roles. For the “grand finale” of my presidency—the President’s Program on May 6 at ACOG’s Annual Clinical Meeting (ACM) in New Orleans—I’ve assembled a roster of phenomenal speakers that will offer their unique spin on these topics.

I’m happy to welcome Malcolm Potts, MD, chair of population and family planning at the University of California Berkeley’s School of Public Health. Dr. Potts has studied extensively the positive societal changes that come when women can make their own reproductive health choices. In a recent speech, Dr. Potts said “If you’re working in cancer or orthopedics or pediatrics, you make people healthier by trying to relieve pain and suffering. What we’ve done in gynecology is change civilization.” His lecture “Sex, Ideology, and Religion: How Family Planning Frees Women and Changes the World” is one not to be missed.

Next, I’ve invited two exceptional leaders, colleagues, and ACOG vice presidents, Sandra A. Carson, MD, and Barbara S. Levy, MD, to present “Your Personal Path to Leadership: The Road Less Traveled.” They’ll discuss their own not-so-traditional journeys to becoming leaders in our field and the need for diversity in leadership.

Rounding out the program, Gary Chapman, PhD, author of The Five Love Languages, will present his speech “The Five Languages of Apology.” His insightful presentation will discuss the importance of apology in developing, maintaining, and repairing relationships.

Though my year as ACOG president is coming to a close, my involvement will continue. I’m looking forward to supporting our new president, Jeanne A. Conry, MD, PhD, in her endeavors and continuing to be an outspoken advocate for women. I’m also looking forward to more time for family and mountain biking in Nevada! Many thanks to ACOG Fellows and staff for your support and friendship throughout this amazing year.

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Guest Blog: Every Reproductive-Age Woman At Risk, Every Time

Frances Casey, MD

Frances Casey, MD

Full implementation of the Affordable Care Act (ACA) will remove many of the financial barriers women face to obtain effective methods of contraception. While making contraception affordable for every woman is a good first step toward improved prevention of unintended pregnancies, it remains the responsibility of health care providers to counsel women about all methods of contraception and help them find the one that may be the most effective.

The CHOICE project demonstrated that removing financial barriers related to the most effective methods of contraception decreases rates of unintended pregnancy and abortion. But the CHOICE project also did something many of us ob-gyns do not. Every reproductive-age woman eligible for the study was read a script about the effectiveness of long-acting reversible contraceptives (LARC), such as intrauterine devices (IUD) and hormonal implants.Instead of discussing LARC with their patients, many providers continue recommending less effective contraceptive methods based on misconceptions that adolescents, women who have never been pregnant, or women they estimate are at high risk for sexually transmitted infections (STIs) are not good candidates for LARCs. However, according to ACOG, LARC is the most effective form of contraception available and safe for use in all of these groups.

Because LARCs don’t require ongoing effort by the user, continuation and correct usage rates are higher. This could significantly reduce unintended pregnancy among teens and women if widely adopted. Additionally, women at high risk of both STIs and unintended pregnancy can be screened, obtain a LARC method the same day, and receive treatment without removing the device. Women with medical conditions and physical and mental disabilities can also benefit from both the pregnancy prevention and the non-contraceptive benefits of LARC.

Other women may also benefit from a longer-acting option. Without strict breastfeeding, postpartum moms are at risk for ovulation and repeat pregnancies even earlier than six weeks after delivery. LARC methods can be inserted immediately following delivery or at four weeks postpartum. Despite slightly higher expulsion rates, the benefits of immediate postpartum insertion of LARC methods may outweigh risks for women who are unlikely to receive postpartum care.

Minimizing financial barriers will make contraceptive methods more accessible for women at risk of unintended pregnancies, but it is up to us, as their partners in prevention, to counsel them on the most effective methods, including LARCs, at every opportunity.

Frances Casey, MD, is a Family Planning Fellow at Washington Hospital Center in DC.

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Guest Blog: The Co-Pay Question—Contraceptive Access Under the ACA

Barbara S. Levy, MD

Barbara S. Levy, MD

If you’ve been to the pharmacy or doctor’s office lately, there’s a good chance that you noticed something different about your bill—there may not have been one. Depending on what type of insurance you have, you may now be eligible to receive all FDA-approved contraception and other preventive health services without a co-pay. This is due to the Affordable Care Act (ACA), a law with a lofty goal: overhauling our current health care system to provide the majority of Americans with affordable access to health care. While the intricacies of the ACA—and health insurance policies—are complex, it’s important for women to understand these most recent changes because they so specifically apply to us.

Whether or not you still have a co-pay for contraceptives depends on where you get your health insurance. More than half of people in the US get their insurance either through their job or by purchasing an individual insurance plan. Currently, the contraceptive coverage provision applies to most of these private plans. Insurance companies that adopted ACA policy changes early on may have already updated their plans to offer free contraception beginning in August 2012. As time passes, more plans will comply. However, there are some exceptions—some plans have grandfathered status that gives them more time to meet the terms of the new requirements, and some religiously affiliated organizations are currently exempt from providing this coverage.

State Medicaid programs already provide no-cost contraception to enrollees. The ACA expands Medicaid’s reach, potentially decreasing the number of uninsured women ages 19–64 from 20% to 8%. Many states are still hammering out exactly how Medicaid provisions will be implemented. ACOG is following this issue closely and supports the adoption of the ACA’s Medicaid expansion in all states.

So how can you find out whether your plan has changed and what new services are covered? You’ll need to ask a few questions and then update your records to be sure your health care team (you, your insurer, pharmacy, and your doctor) is on the same page:

  • Ask your employer or your health insurer whether the ACA has caused any significant changes to your plan. If so, what are they, and specifically, is contraception now covered without a co-pay?
  • If there are updates to your plan, be sure to notify your pharmacy and your doctor’s office and report any problems to your plan administrator or insurance company. It’s up to you to be sure you’re being charged correctly based on what your policy covers.

As an ob-gyn, I am thrilled by the increased availability of no-cost contraception that the ACA provides. Contraception is a basic health necessity for women. More access puts women in the driver’s seat, helping us avoid unintended pregnancy and take control of our reproductive health.

Learn more about contraceptive coverage and the ACA.

Barbara S. Levy, MD, is vice president of health policy at ACOG.

Guest Blog: Why Expanding Medicaid Matters for Women

Gerald F. Joseph Jr, MD

Many women in the United States do not have health insurance. As a result, they don’t get the health care they need and their health suffers. Compared to women with health insurance, uninsured women are:

* Less likely to receive preventive care or treatment for disease.

* More likely to be diagnosed with cervical and other cancers at a late stage and die from the disease or its complications due to a delay in diagnosis.

* Less likely to get prenatal care during pregnancy. The babies of uninsured women are also more likely to be born with a low birthweight and die within the first year of life.

* Less likely to use a prescription contraceptive, which can lead to unintended pregnancy.

The Affordable Care Act (ACA) can help. It expands Medicaid—the state-federal health insurance program for low-income individuals—which is one of the health care reform provisions that ACOG supports. The percentage of uninsured women ages 19–64 could decrease from 20% to 8%, but this will happen only if all 50 state governors decide to expand their Medicaid programs. ACOG encourages all states to accept this expansion offer, under which the federal government will pay all the costs until 2016. After that, the federal contribution gradually drops, but only to 90% in 2020 and beyond.

The ACA also makes it easier for states to provide Medicaid birth control coverage to low-income women by eliminating bureaucratic red tape.

With Election Day approaching rapidly, I encourage you to find out what the candidates in your state support. Use your vote to make it clear to your state lawmakers that expansion of Medicaid is good for women’s health.

For more information:

Protect Medicaid and Women’s Health

What the Medicaid Eligibility Expansion Means for Women

Medicaid Expansion Resources

Gerald F. Joseph Jr, MD, is ACOG vice president for practice activities.

Guest Blog: The Recipe for Preventing Unintended Pregnancy

Erika E. Levi, MD, MPH

Ob-gyns are on the front lines of the effort to decrease the rate of unintended pregnancy, which accounts for half of all pregnancies in the US. Now, we have more information about how we can best accomplish this goal.

Recent findings from the Contraceptive CHOICE Project made news headlines, and for good reason. The project—which included more than 9,000 contraception-seeking adolescents and women in the St. Louis region who were at risk for unintended pregnancy—found that the rate of unintended pregnancy dropped with just two simple interventions. Women were given:

  1. A short contraceptive counseling session that covered all methods of reversible contraception and emphasized the superior effectiveness of long-acting reversible contraception (LARC) methods: intrauterine devices (IUDs) and hormonal implants.
  2. The contraceptive method of their choice for free.

Seventy-five percent of the women selected a LARC method. Among all the women, there were lower rates of abortion, including repeat abortion, and lower rates of teen births. These findings support ACOG’s recommendations on the use of LARC methods as first-line contraceptive options to reduce unintended pregnancy and highlight the benefits of providing women with no-cost access to contraception.

ACOG advises ob-gyns to:

  • Provide counseling on all contraceptive options, including implants and IUDs, even if the patient initially states a preference for a specific contraceptive method
  • Encourage implants and IUDs for all appropriate women, including those who’ve never given birth
  • Adopt same-day insertion protocols. Screening for STIs may also occur on the day of insertion, if indicated
  • Avoid unnecessary delays to LARC initiation, such as waiting for a follow-up visit after an abortion or miscarriage or waiting to time insertion with the menstrual cycle
  • Advocate for coverage of all contraceptive methods by all insurance plans
  • Support local, state, federal, and private programs that provide contraception, including IUDs and implants

The problem of unintended pregnancy in the US is not going away. As ob-gyns, we are uniquely positioned to help women avoid unintended pregnancies. Let’s work with our patients and help them make the best choices for their reproductive health.

Erika E. Levi, MD, MPH, is a Family Planning Fellow at the University of North Carolina at Chapel Hill.

Guest Blog: Prevent Teen Pregnancy on a LARC

Elisabeth J. Woodhams, MD

In my Chicago clinic I see a lot of adolescents, and by extension, I prescribe a lot of contraception. Although, by “prescribe contraception” I actually mean “place IUDs and implants,” which, until recently, had been considered a fairly edgy clinical practice in some circles. Imagine my excitement, then, over ACOG’s latest recommendations from the Committee on Adolescent Health Care and the Long-Acting Contraception Work Group that encourage us to offer these two contraceptive methods as first-line options for sexually active teens.

Family planning specialists have long known that long-acting reversible contraception (LARC) devices are safe for adolescents and are significantly more effective at preventing pregnancy when compared with other forms of short-acting contraception, such as pills, patches, or vaginal rings. In fact, a recent study found that women using a LARC device were 20 times less likely to experience an unplanned pregnancy than women using short-acting methods. This is hugely important considering that:

  • 82% of adolescent pregnancies are unplanned
  • 20% of adolescent mothers will experience a second pregnancy within two years of their first pregnancy
  • Condoms are the most common method of contraception used by adolescents. While still important for preventing sexually transmitted infections (STIs), they are the least effective contraceptive method for preventing pregnancy.

LARC methods work better than short-acting ones because there’s no user error. As I tell my patients, a pack of pills only works if you’re actually taking them. Also, the continuation rates are better—in that same study, 86% of adolescents using a LARC device were still using it a year later, compared with 55% of those using a shorter-acting method.

And LARC methods are very safe for adolescents:

  •  IUD expulsion is uncommon in adolescents
  • There is no increased risk of infertility for IUD users
  • Any increased risk of pelvic inflammatory diseases (PID) is limited to the first 20 days after insertion of an IUD and is related to infection at the time of insertion rather than the IUD itself. This is another important reason ob-gyns should screen all their patients under 25 for chlamydia and gonorrhea annually.
  • IUDs and implants can be placed immediately post-delivery or post-abortion
  • IUDs and implants can decrease menstrual blood loss and decrease anemia, a plus for many teens

So make sure LARC methods are at the top of your list when you’re counseling adolescent patients. For many teens, LARC devices—combined with condoms for STI prevention—are the best way to ensure they get on the right reproductive track early.

Elisabeth J. Woodhams, MD, is a Family Planning Fellow at the University of Chicago in Illinois.