Abstract
Over 26 million people in the United States have been infected with the novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) as of February 2021, resulting in >450,000 deaths. 1 In addition to the health care consequences of coronavirus disease 2019 (COVID-19), there have been deep financial repercussions. Widespread closures of cities slowed transmission, but also caused significant job loss, disproportionately affecting women, especially Black and Latinx women. 2 More than half of COVID-19 cases are among women 1 and women have lost 1 million more net jobs than men since the start of the pandemic. 3
Access to contraception is especially important during periods of financial instability. Pregnancy decreases a woman's earnings and accessing contraception increases her earning power. 4 Yet, due to COVID-19's unprecedented strain on the health care system and to prioritize social distancing, many hospitals delayed all “nonessential” health care visits that often include contraception provision. This decision has led to unplanned pregnancies for many women such as my patient “Sarah.”
Sarah had her contraceptive implant removed and was scheduled for a sterilization surgery in March 2020. When the pandemic halted all “elective procedures,” her surgery was cancelled. As she did not meet criteria for an in-person visit, and our department had not yet established telemedicine appointments, she continued to rely on condoms for contraception. In June, Sarah was found to be 6 weeks pregnant. Although unplanned and undesired, given her personal beliefs, she continued the pregnancy. In July she had an ultrasonography that showed a fetus with a large cystic hygroma, skin edema, and pleural effusions; chorionic villus sampling confirmed a diagnosis of Turner's syndrome. Sarah decided to terminate the pregnancy and had an uncomplicated abortion in mid-August. Once our hospital was able to restart elective procedures, after improvement in both the local test positivity rates and personal protective equipment supplies, Sarah's sterilization was rescheduled for the end of August. The day before her scheduled surgery, she was tested for SARS-CoV-2—and tested positive. Sarah's surgery was postponed and as she quarantined for the next 2 weeks, she relied, once again, on condoms.
Sarah is not alone. One in three women report that they have had a delay or cancelled visit for their reproductive health due to the COVID-19 pandemic that has disproportionately affected Black (38%) and Hispanic (45%) women, compared with White (29%).
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Although we have seen tremendous progress in implementing telemedicine and health care delivery innovation, reproductive health has been left behind. To obtain a refill for a birth control pill, patch, or ring, for example, 75% of patients state that their provider continues to require an in-person visit.
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A patient who uses depot-medroxyprogesterone acetate (DMPA) continues to be seen by a nurse for her intramuscular (IM) injection every 3 months. Similarly, a postpartum patient desiring a long acting reversible contraception (LARC) device often cannot obtain an LARC unless they have an in-person postpartum visit, because in most states, insurance will not cover devices placed immediately postpartum.
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In an era wherein we are striving to minimize in-person contact, rather than cancelling our patients' “nonessential” contraception visits, it is time to reshape contraception delivery in the following ways: Remove the prescription requirements for short-acting hormonal methods of contraception. Dispensing a 12-month supply of short-acting contraceptive methods, as opposed to the traditional 3-month supply, reduces unintended pregnancies by minimizing gaps in contraception.
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Although some states have implemented this change, it is not enough. Before the pandemic, a national survey of 1,385 women showed that 29% of those who tried to obtain a prescription for a hormonal method of contraception had problems accessing the initial prescription or the refill.
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If we continue to require prescriptions for short-acting hormonal contraceptives, this number will increase due to COVID-19–related restrictions on ambulatory care given the “nonessential” nature of contraception visits. Data support the safety of patient self-screening for contraindications to hormonal contraception. Provider and patient screening results in agreement >95% of the time, and in cases of discrepancy, women were more conservative than the health care providers in identifying themselves as having a contraindication when they really did not.
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It is time we urge pharmaceutical companies to make short-acting hormonal contraceptives available over the counter. Over the counter availability of the contraceptive pill, patch, and ring will eliminate an unnecessary nonessential visit while increasing access to these forms of contraception. Expand administration options for DMPA DMPA is an injectable contraceptive that is administered every 3 months either IM or subcutaneously (SC) with equal efficacy of the two administration methods. DMPA-SC was created for the possibility of self-administration. However, inconsistent insurance coverage for DMPA-SC poses a barrier to access. Legislators in California responded to COVID-19 by utilizing a new waiver to approve DMPA-SC as a pharmacy benefit, and a preliminary implementation study has shown successful initiation of self-administered DMPA-SC.
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Further expansion of coverage for DMPA-SC will help patients maintain consistent use of the medication while adhering to social distancing recommendations. In addition, allowing pharmacists to administer DMPA could ensure increased access for those who do not feel comfortable with self-injections. Increase access to immediate postpartum LARC LARC methods, including intrauterine devices and the subdermal implant, are the most effective forms of contraception and can be placed by a provider during the hospital admission after childbirth. Yet Medicaid reimbursement for the LARC device and the insertion procedure in the immediate postpartum period is only available in ∼18 states.
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Thus, most patients who desire postpartum LARC must wait until their postpartum visit for the costs of placement to be covered. In the era of COVID-19, most postpartum visits are now conducted through telemedicine, and thus the patients who desire postpartum LARC are left without. Expanding insurance coverage for postpartum LARC will increase access to LARC methods for mothers with newborns, helping them achieve their desired birth spacing.
COVID-19 has forced us to alter the way we practice medicine, bringing the question “is it necessary for this visit to be in person?” to the forefront of every patient encounter. We have new opportunities to improve service delivery. Implementing these new contraception delivery methods and expanded coverage may also help to reduce health care disparities. We have been challenged to rapidly adapt our practice to fit this new model, and as we rise to the occasion, let us ensure that we do not leave reproductive health behind.