www.AJOG.org
Editorials
Beyond consent to sterilization: facing up to the full range of barriers to post-abortion contraception Adam Sonfield, MPP; Rachel Benson Gold, MPA
A
n article in this issue by researchers (Krashin and colleagues)1 from the Oregon Health and Science University argues for the elimination of decades-old restrictions on postabortion sterilization, which were enacted as safeguards for US women in response to the well-documented instances of coercive sterilization, particularly among low-income women of color. The authors assert that restrictions on sterilization under Medicaid and other federal health programs, including a 30-day waiting period after providing written consent and particularly a ban on providing consent to sterilization by women seeking or obtaining an abortion, violate women’s rights and pose risks to their health. In addition, their study1 provides estimates of the potential impact of removing these restrictions, including substantial projected reductions in unintended pregnancies and the medical costs related to such pregnancies and substantial increases in quality-adjusted life-years. Although the authors do not highlight this, it appears that much of the estimated impact of their preferred policy change stems from the assumptions that if postabortion sterilization is not available, many women (43%, according to Table 1) will not use any method of contraception at all, and many other women will start a method but soon discontinue it. These underlying assumptions reflect long-standing problems with the provision of all types of contraception, permanent or reversible, in a postabortion context. The vast majority of US abortions (70% in 2008) are performed at specialized clinics, defined as those clinics at which at least half of their annual patient visits are for abortion care.2 The remainder are performed primarily at reproductive health centers with a broader focus (24%), with a small number (4%) performed at hospitals. Although this arrangement has resulted in a strong record of safe and quality abortion care, it has also resulted in a less-than-ideal situation for the provision of postabortion contraception. According to a 2008-2009 Guttmacher Institute study, most specialized abortion providers were not set up to provide a wide array of contraceptive methods and were less
From the Guttmacher Institute, Washington, DC. Received May 15, 2014; accepted May 15, 2014. The authors report no conflict of interest. Reprints: Adam Sonfield, MPP, Guttmacher Institute, 1301 Connecticut Ave. NW, #700, Washington, DC 20036. asonfi[email protected]. 0002-9378/free ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.05.021
See related article, page 76
likely than providers with a broader focus to offer intrauterine devices (IUDs) and implants, whether immediately after the abortion or separately.3 They were also less likely to use evidence-based strategies for improving contraceptive use, such as a quick-start initiation of oral contraceptives. One set of barriers to improved postabortion contraception involves patients’ perceptions and expectations of specialized abortion clinics.4 These providers are not typically viewed, or set up to serve, as places to go for comprehensive, ongoing care. Abortion patients often travel long distances to a clinic, may have no interest or reason to make repeat visits, often do not return for follow-up care for the abortion itself, and are likely to have other, local providers on whom they rely for contraceptive care. Second, because their patients come to them specifically for abortion care, many of these providers have insufficient training, experience, and comfort in providing other types of care, including the insertion of IUDs and implants, and sterilization procedures. One recent study found that facilities with clinicians recently trained in inserting IUDs and implants were particularly likely to offer those methods, and their patients were particularly likely to use them.5 Additional barriers involve costs and reimbursement. Many contraceptive methods, and particularly the most effective methods, have high up-front costs, despite being extremely cost effective in the long run. These high costs are particularly problematic in an abortion setting because abortion in the United States is increasingly concentrated among low-income women.6 These women often struggle to pay for the abortion procedure itself along with related expenses such as transportation, a hotel, and child care; additional costs for contraception only compound these problems. Public and private health insurance is designed to address these cost issues. However, in most states, Medicaid is barred from paying for abortion except in extremely limited circumstances, and many states also ban abortion coverage in some or all private insurance plans.7,8 Women may also avoid using insurance for confidentiality reasons or for logistical issues (such as high deductibles); all told, about two-thirds of the privately insured abortion patients end up paying out of pocket.6 Given all this, it should not be surprising that many specialized abortion clinics have little experience with health insurance: in 2009, only 60% of them accepted either private insurance or Medicaid for abortion, and only 55% for contraception.4 Even when they do accept insurance, reimbursement rates and structures can be difficult to keep track of and can lead to additional problems.9 For example, many insurance contracts call for a single, bundled reimbursement rate for abortion, which includes all follow-up care, including contraception, by the same provider within a set time frame. Unless providers JULY 2014 American Journal of Obstetrics & Gynecology
3
www.AJOG.org
Editorials can secure additional reimbursement for a secondary procedure such as the insertion of an IUD or tubal ligation (something that should be possible with proper coding and billing but is often difficult or inadequate in practice), they face a severe financial disincentive to providing those methods at all after the abortion. Instead, they often provide samples of short-term contraceptives, the cost of which can more easily be absorbed into a bundled rate.3 Specialized clinics may also face issues related to preauthorization requirements for higher-cost contraceptive methods, requirements for patients to purchase a contraceptive device ahead of time through their pharmacy benefit, and difficulties securing insurance contracts for services beyond abortion.9 Restrictions on Medicaid coverage of abortion can also dissuade providers from seeking reimbursement for postabortion contraceptive services, even though such reimbursement is fully legal. In fact, because of these restrictions, many specialized abortion clinics have no connection to Medicaid at all and would need to gain considerable expertise and develop new systems to begin billing the program for contraceptive services. All of these problems point to a third alternative scenario that is not explored by Krashin and colleagues1 in their analysis: improving the provision of postabortion reversible contraception. Many of the key barriers to this provision are fully surmountable. Abortion providers could seek out more training, or new clinicians could be brought on to fill gaps in clinics’ contraceptive expertise. Clinics could restructure how and when they provide information and counseling about contraceptive options to their patients to reduce patient anxiety and encourage full consideration of their options. They could take steps to refer patients to contraceptive care at more comprehensive reproductive health centers and facilitate follow-up care by phone or with patients’ regular providers. Moreover, clinics could make new efforts to gain contracts with public and private health plans, and they have incentives to do so because increasing numbers of their patients will have insurance because of the Affordable Care Act. And state and federal Medicaid officials could address many reimbursement issues for postabortion contraception. For example, they could designate specific billing codes for
4 American Journal of Obstetrics & Gynecology JULY 2014
postabortion procedures outside bundled rates, signal to providers and Medicaid managed care plans that they encourage postabortion contraception as an important way to reduce the incidence of repeat unintended pregnancy, and encourage specialized abortion clinics to participate in Medicaid as providers of contraception. If Medicaid takes the lead, private health plans may follow suit. Notably, most of these barriers to reversible contraception could be addressed without requiring major changes to any existing federal or state laws or regulations, and they do not raise any of the difficult ethical issues involved in altering or eliminating the current restrictions on publicly funded sterilization. And, in fact, the same obstacles to providing reversible contraception after an abortion would stand in the way of postabortion sterilization, and in the way of the potential benefits to women and society that Krashin and colleagues1 have projected, even if the restrictions on consent to sterilization were removed. REFERENCES 1. Krashin JW, Edelman AB, Nichols MD, et al. Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care? Am J Obstet Gynecol 2014;211:76.e1-10. 2. Jones RK, Kooistra K. Abortion incidence and access to services in the United States, 2008. Perspect Sex Reprod Health 2011;43:41-50. 3. Kavanaugh ML, Jones RK, Finer LB. How commonly do US abortion clinics offer contraceptive services? Contraception 2010;82:331-6. 4. Kavanaugh ML, Jones RK, Finer LB. Perceived and insurance-related barriers to the provision of contraceptive services in US abortion care settings. Womens Health Issues 2011;21:S26-31. 5. Thompson KM, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception 2011;83:41-7. 6. Jones RK, Finer LB, Singh S. Characteristics of US abortion patients, 2008. New York: Guttmacher Institute; 2010. 7. Guttmacher Institute. State funding of abortion under Medicaid. State policies in brief (as of May 1, 2014). 2014. Available at: http://www. guttmacher.org/statecenter/spibs/spib_SFAM.pdf. Accessed May 12, 2014. 8. Guttmacher Institute. Restricting insurance coverage of abortion. State policies in brief (as of May 1, 2014). 2014. Available at: http://www. guttmacher.org/statecenter/spibs/spib_RICA.pdf. Accessed May 12, 2014. 9. Sonfield A. Abortion clinics and contraceptive services: opportunities and challenges. Guttmacher Policy Review 2011;14(2):2-7.
Editorials
Beyond consent to sterilization: facing up to the full range of barriers to post-abortion contraception Adam Sonfield, MPP; Rachel Benson Gold, MPA
A
n article in this issue by researchers (Krashin and colleagues)1 from the Oregon Health and Science University argues for the elimination of decades-old restrictions on postabortion sterilization, which were enacted as safeguards for US women in response to the well-documented instances of coercive sterilization, particularly among low-income women of color. The authors assert that restrictions on sterilization under Medicaid and other federal health programs, including a 30-day waiting period after providing written consent and particularly a ban on providing consent to sterilization by women seeking or obtaining an abortion, violate women’s rights and pose risks to their health. In addition, their study1 provides estimates of the potential impact of removing these restrictions, including substantial projected reductions in unintended pregnancies and the medical costs related to such pregnancies and substantial increases in quality-adjusted life-years. Although the authors do not highlight this, it appears that much of the estimated impact of their preferred policy change stems from the assumptions that if postabortion sterilization is not available, many women (43%, according to Table 1) will not use any method of contraception at all, and many other women will start a method but soon discontinue it. These underlying assumptions reflect long-standing problems with the provision of all types of contraception, permanent or reversible, in a postabortion context. The vast majority of US abortions (70% in 2008) are performed at specialized clinics, defined as those clinics at which at least half of their annual patient visits are for abortion care.2 The remainder are performed primarily at reproductive health centers with a broader focus (24%), with a small number (4%) performed at hospitals. Although this arrangement has resulted in a strong record of safe and quality abortion care, it has also resulted in a less-than-ideal situation for the provision of postabortion contraception. According to a 2008-2009 Guttmacher Institute study, most specialized abortion providers were not set up to provide a wide array of contraceptive methods and were less
From the Guttmacher Institute, Washington, DC. Received May 15, 2014; accepted May 15, 2014. The authors report no conflict of interest. Reprints: Adam Sonfield, MPP, Guttmacher Institute, 1301 Connecticut Ave. NW, #700, Washington, DC 20036. asonfi[email protected]. 0002-9378/free ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.05.021
See related article, page 76
likely than providers with a broader focus to offer intrauterine devices (IUDs) and implants, whether immediately after the abortion or separately.3 They were also less likely to use evidence-based strategies for improving contraceptive use, such as a quick-start initiation of oral contraceptives. One set of barriers to improved postabortion contraception involves patients’ perceptions and expectations of specialized abortion clinics.4 These providers are not typically viewed, or set up to serve, as places to go for comprehensive, ongoing care. Abortion patients often travel long distances to a clinic, may have no interest or reason to make repeat visits, often do not return for follow-up care for the abortion itself, and are likely to have other, local providers on whom they rely for contraceptive care. Second, because their patients come to them specifically for abortion care, many of these providers have insufficient training, experience, and comfort in providing other types of care, including the insertion of IUDs and implants, and sterilization procedures. One recent study found that facilities with clinicians recently trained in inserting IUDs and implants were particularly likely to offer those methods, and their patients were particularly likely to use them.5 Additional barriers involve costs and reimbursement. Many contraceptive methods, and particularly the most effective methods, have high up-front costs, despite being extremely cost effective in the long run. These high costs are particularly problematic in an abortion setting because abortion in the United States is increasingly concentrated among low-income women.6 These women often struggle to pay for the abortion procedure itself along with related expenses such as transportation, a hotel, and child care; additional costs for contraception only compound these problems. Public and private health insurance is designed to address these cost issues. However, in most states, Medicaid is barred from paying for abortion except in extremely limited circumstances, and many states also ban abortion coverage in some or all private insurance plans.7,8 Women may also avoid using insurance for confidentiality reasons or for logistical issues (such as high deductibles); all told, about two-thirds of the privately insured abortion patients end up paying out of pocket.6 Given all this, it should not be surprising that many specialized abortion clinics have little experience with health insurance: in 2009, only 60% of them accepted either private insurance or Medicaid for abortion, and only 55% for contraception.4 Even when they do accept insurance, reimbursement rates and structures can be difficult to keep track of and can lead to additional problems.9 For example, many insurance contracts call for a single, bundled reimbursement rate for abortion, which includes all follow-up care, including contraception, by the same provider within a set time frame. Unless providers JULY 2014 American Journal of Obstetrics & Gynecology
3
www.AJOG.org
Editorials can secure additional reimbursement for a secondary procedure such as the insertion of an IUD or tubal ligation (something that should be possible with proper coding and billing but is often difficult or inadequate in practice), they face a severe financial disincentive to providing those methods at all after the abortion. Instead, they often provide samples of short-term contraceptives, the cost of which can more easily be absorbed into a bundled rate.3 Specialized clinics may also face issues related to preauthorization requirements for higher-cost contraceptive methods, requirements for patients to purchase a contraceptive device ahead of time through their pharmacy benefit, and difficulties securing insurance contracts for services beyond abortion.9 Restrictions on Medicaid coverage of abortion can also dissuade providers from seeking reimbursement for postabortion contraceptive services, even though such reimbursement is fully legal. In fact, because of these restrictions, many specialized abortion clinics have no connection to Medicaid at all and would need to gain considerable expertise and develop new systems to begin billing the program for contraceptive services. All of these problems point to a third alternative scenario that is not explored by Krashin and colleagues1 in their analysis: improving the provision of postabortion reversible contraception. Many of the key barriers to this provision are fully surmountable. Abortion providers could seek out more training, or new clinicians could be brought on to fill gaps in clinics’ contraceptive expertise. Clinics could restructure how and when they provide information and counseling about contraceptive options to their patients to reduce patient anxiety and encourage full consideration of their options. They could take steps to refer patients to contraceptive care at more comprehensive reproductive health centers and facilitate follow-up care by phone or with patients’ regular providers. Moreover, clinics could make new efforts to gain contracts with public and private health plans, and they have incentives to do so because increasing numbers of their patients will have insurance because of the Affordable Care Act. And state and federal Medicaid officials could address many reimbursement issues for postabortion contraception. For example, they could designate specific billing codes for
4 American Journal of Obstetrics & Gynecology JULY 2014
postabortion procedures outside bundled rates, signal to providers and Medicaid managed care plans that they encourage postabortion contraception as an important way to reduce the incidence of repeat unintended pregnancy, and encourage specialized abortion clinics to participate in Medicaid as providers of contraception. If Medicaid takes the lead, private health plans may follow suit. Notably, most of these barriers to reversible contraception could be addressed without requiring major changes to any existing federal or state laws or regulations, and they do not raise any of the difficult ethical issues involved in altering or eliminating the current restrictions on publicly funded sterilization. And, in fact, the same obstacles to providing reversible contraception after an abortion would stand in the way of postabortion sterilization, and in the way of the potential benefits to women and society that Krashin and colleagues1 have projected, even if the restrictions on consent to sterilization were removed. REFERENCES 1. Krashin JW, Edelman AB, Nichols MD, et al. Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care? Am J Obstet Gynecol 2014;211:76.e1-10. 2. Jones RK, Kooistra K. Abortion incidence and access to services in the United States, 2008. Perspect Sex Reprod Health 2011;43:41-50. 3. Kavanaugh ML, Jones RK, Finer LB. How commonly do US abortion clinics offer contraceptive services? Contraception 2010;82:331-6. 4. Kavanaugh ML, Jones RK, Finer LB. Perceived and insurance-related barriers to the provision of contraceptive services in US abortion care settings. Womens Health Issues 2011;21:S26-31. 5. Thompson KM, Speidel JJ, Saporta V, Waxman NJ, Harper CC. Contraceptive policies affect post-abortion provision of long-acting reversible contraception. Contraception 2011;83:41-7. 6. Jones RK, Finer LB, Singh S. Characteristics of US abortion patients, 2008. New York: Guttmacher Institute; 2010. 7. Guttmacher Institute. State funding of abortion under Medicaid. State policies in brief (as of May 1, 2014). 2014. Available at: http://www. guttmacher.org/statecenter/spibs/spib_SFAM.pdf. Accessed May 12, 2014. 8. Guttmacher Institute. Restricting insurance coverage of abortion. State policies in brief (as of May 1, 2014). 2014. Available at: http://www. guttmacher.org/statecenter/spibs/spib_RICA.pdf. Accessed May 12, 2014. 9. Sonfield A. Abortion clinics and contraceptive services: opportunities and challenges. Guttmacher Policy Review 2011;14(2):2-7.
