News Contraception

IOM Recommends Full Coverage of Contraceptives, Other Reproductive Health Care Under Health Reform

Jodi Jacobson

In a new--and much-anticipated--report, the Institute of Medicine recommends that health reform guidelines for preventive care to be developed by the HHS include no-copay for contraception and a wide range of preventive services.

All articles included in Rewire’s coverage of the IOM Report can be found here.

In a new–and much-anticipated–report, the Institute of Medicine (IOM) is recommending that health reform guidelines for preventive care to be developed by the U.S. Department of Health and Human Services (HHS) include a full range of reproductive health services, including all methods of contraception approved by the Food and Drug Administration (FDA) without a co-pay.  In developing these and other recommendations for women’s preventive health care, the IOM took into account the recommendations of medical bodies and of peer-reviewed studies demonstrating important health needs and outcomes.

Apart from coverage of contraceptive supplies, the IOM also breaks new ground with recommendations on inclusion of screening for gender-based and domestic violence, education, testing, and counseling for sexually transmitted infections, and inclusion of other essentials to a broader package of “well-woman” care as part of basic insurance coverage.

In total, the IOM report recommends inclusion of eight preventive health services for women at no cost under the Patient Protection and Affordable Care Act of 2010 (ACA). The ACA requires plans to cover the services listed in HHS’s comprehensive list of preventive services.  At the agency’s request, an IOM committee identified critical gaps in preventive services for women as well as measures that will further ensure women’s health and well-being.

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HHS has set its own self-imposed deadline of August 2nd for release of these final guidelines.

The IOM recommends that HHS including the following as part of standard preventive care guidelines for women:

  • Screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes.
  • The addition of high-risk human papillomavirus DNA testing in addition to conventional cytology testing in women with normal cytology results. Screening should begin at 30 years of age and should occur no more frequently than every 3 years.
  • Annual counseling on sexually transmitted infections for all sexually active women.
  • Counseling and screening for human immunodeficiency virus infection on an annual basis for sexually active women.
  • The full range of Food and Drug Administration-approved contraceptive methods,
    sterilization procedures, and patient education and counseling for all women with reproductive capacity.
  • Comprehensive lactation support and counseling and costs of renting breastfeeding equipment. A trained provider should provide counseling services to all pregnant women and to those in the postpartum period to ensure the successful initiation and duration of breastfeeding. (The ACA ensures that
    breastfeeding counseling is covered; however, the committee recognizes that interpretation of this varies.)
  • Screening and counseling for interpersonal and domestic violence. Screening and
    counseling involve elicitation of information from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems.
  • At least one well-woman preventive care visit annually for adult women to obtain
    the recommended preventive services, including preconception and prenatal care. The committee also recognizes that several visits may be needed to obtain
    all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors.

The report asks HHS to strengthen some already-existing practices for women’s health care.  For example, it notes that while lactation counseling is already part of the HHS guidelines, the report recommends comprehensive support that includes coverage of breast pump rental fees as well as counseling by trained providers to help women initiate and continue breast-feeding. Evidence links breast-feeding to lower risk for breast and ovarian cancers; it also reduces children’s risk for sudden infant death syndrome, asthma, gastrointestinal infections, respiratory diseases, leukemia, ear infections, obesity, and Type 2 diabetes.

Likewise, the IOM notes that deaths from cervical cancer could be reduced by adding DNA testing for HPV, the virus that can cause this form of cancer, to the Pap smears that are part of the current guidelines for women’s preventive services.  Cervical cancer can be prevented through vaccination, screening, and treatment of precancerous lesions and HPV testing increases the chances of identifying women at risk. 

And in regard to contraceptive coverage, the IOM report states:

To reduce the rate of unintended pregnancies, which accounted for almost half of pregnancies in the U.S. in 2001, the report urges that HHS consider adding the full range of Food and Drug Administration-approved contraceptive methods as well as patient education and counseling for all women with reproductive capacity.  Women with unintended pregnancies are more likely to receive delayed or no prenatal care and to smoke, consume alcohol, be depressed, and experience domestic violence during pregnancy.  Unintended pregnancy also increases the risk of babies being born preterm or at a low birth weight, both of which raise their chances of health and developmental problems.

 The IOM also recommend that HHS should consider screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes.  “The United States has the highest rates of gestational diabetes in the world,” states the report. “It complicates as many as 10 percent of U.S. pregnancies each year.  Women with gestational diabetes face a 7.5-fold increased risk for the development of Type 2 diabetes after delivery and are more likely to have infants that require delivery by cesarean section and have health problems after birth.”

The conclusions for the final report were drawn after a review by IOM of evidence and testimony from experts on the most critical public health problems particular to women.

The recommendations are based on a review of existing guidelines and an assessment of the evidence on the effectiveness of different preventive services.  The committee identified diseases and conditions that are more common or more serious in women than in men or for which women experience different outcomes or benefit from different interventions.

To develop the recommendations, the IOM convened a committee of experts to identify critical gaps in the preventive services already identified in the ACA, which are based on recommendations developed by three independent bodies: the United States Preventive Services Task Force, the American Academy of Pediatrics’ Bright Futures recommendations for adolescents, and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices.

As the report notes, “the committee defined preventive health services as measures—
including medications, procedures, devices, tests, education and counseling—
shown to improve well-being, and/or decrease the likelihood or delay the onset of a targeted disease or condition.”

To guide its deliberations, the committee developed four overarching questions:

  • Are high-quality systematic evidence reviews available which indicate that the service is effective in women?
  • Are quality peer-reviewed studies available demonstrating effectiveness of the service in women?
  • Has the measure been identified as a federal priority to address in women’s preventive services?
  • Are there existing federal, state, or international practices, professional guidelines, or federal reimbursement policies that support the use of the measure?

Preventive measures recommended by the IOM committee for preventive coverage consideration met the following criteria:

• The condition to be prevented affects a broad population;

• The condition to be prevented has a large potential impact on health and well-being; and
• The quality and strength of the evidence is supportive.

To put it all simply, the IOM did what medical professionals are supposed to do.  They looked at the hard evidence on what women need to be healthy and to make healthy choices for themselves, and for their families.  And they recommended health care guidelines be developed based on what would be the greatest good for the greatest number.

Moreover, IOM sees this as an ongoing process of promoting excellence in women’s health care, recommending regular review of the guidelines as new evidence is developed.

HHS’s guidelines on preventive health services for women will need to be updated routinely in light of new science.  As part of this process, HHS should establish a commission to recommend which services health plans should cover, the report says.  The commission should be separate from the groups that assess evidence of health services’ effectiveness, and it should consider cost-effectiveness analyses, evidence reviews, and other information to make coverage recommendations.

“This report provides a road map for improving the health and well-being of women,” said committee chair Linda Rosenstock, dean, School of Public Health, University of California, Los Angeles.  “The eight services we identified are necessary to support women’s optimal health and well-being.  Each recommendation stands on a foundation of evidence supporting its effectiveness.”

Based on previous positions on reproductive health care services in the health reform bill, reaction to the report’s recommendations, particularly on birth control and ongoing sexual health education and counseling for from groups like the United States Council on Catholic Bishops, the Family Research Council and other vehemently anti-choice groups is expected to be fiercely negative.  For these and other reasons, health and rights groups will likely be working hard between now and August 2nd to ensure that HHS includes these scientifically and medically sound recommendations in its policies for no-cost health care.

Tomorrow: Analysis of the reports recommendations for changing women’s health care.

Commentary Contraception

The Promotion of Long-Acting Contraceptives Must Confront History and Center Patient Autonomy

Jamila Taylor

While some long-acting reversible contraceptive methods were used to undermine women of color's reproductive freedom, those methods still hold the promise of reducing unintended pregnancy among those most at risk.

Since long-acting reversible contraceptives (LARCs), including intrauterine devices and hormonal contraceptive implants, are among the most effective means of pregnancy prevention, many family planning and reproductive health providers are increasingly promoting them, especially among low-income populations.

But the promotion of LARCs must come with an acknowledgment of historical discriminatory practices and public policy related to birth control. To improve contraceptive access for low-income women and girls of color—who bear the disproportionate effects of unplanned pregnancy—providers and advocates must work to ensure that the reproductive autonomy of this population is respected now, precisely because it hasn’t been in the past.

For Black women particularly, the reproductive coercion that began during slavery took a different form with the development of modern contraceptive methods. According to Dorothy Roberts, author of Killing the Black Body, “The movement to expand women’s reproductive options was marked with racism from its very inception in the early part of [the 20th] century.” Decades later, government-funded family planning programs encouraged Black women to use birth control; in some cases, Black women were coerced into being sterilized.

In the 1990s, the contraceptive implant Norplant was marketed specifically to low-income women, especially Black adults and teenage girls. After a series of public statements about the benefits of Norplant in reducing pregnancy among this population, policy proposals soon focused on ensuring usage of the contraceptive method. Federal and state governments began paying for Norplant and incentivizing its use among low-income women while budgets for social support programs were cut. Without assistance, Norplant was not an affordable option, with the capsules costing more than $300 and separate, expensive costs for implantation and removal.

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Soon, Norplant was available through the Medicaid program. Some states introduced (ultimately unsuccessful) bills that would give cash rewards to entice low-income women on public assistance into using it; a few, such as Tennessee and Washington state, required that women receiving various forms of public assistance get information about Norplant. After proposing a bill to promote the use of Norplant in his state in 1994, a Connecticut legislator made the comment, “It’s far cheaper to give you money not to have kids than to give you money to have kids.” By that year, as Roberts writes, states had spent $34 million on Norplant-related care, much of it for women on Medicaid. Policymakers thought it was completely legitimate and cost-effective to control the reproduction of low-income women.

However, promoting this method among low-income Black women and adolescents was problematic. Racist, classist ideology dictating that this particular population of women shouldn’t have children became the basis for public policy. Even though coercive practices in reproductive health were later condemned, these practices still went on to shape cultural norms around race and gender, as well as medical practice.

This history has made it difficult to move beyond negative perceptions, and even fear, of LARCs, health care, and the medical establishment among some women of color. And that’s why it’s so important to ensure informed consent when advocating for effective contraceptive methods, with choice always at the center.

But how can policies and health-care facilities promote reproductive autonomy?

Health-care providers must deal head on with the fact that many contemporary women have concerns about LARCs being recommended specifically to low-income women and women of color. And while this is part of the broader effort to make LARCs more affordable and increasingly available to communities that don’t have access to them, mechanisms should be put in place to address this underlying issue. Requiring cultural competency training that includes information on the history of coercive practices affecting women of color could help family planning providers understand this concern for their patients.

Then, providers and health systems must address other barriers that make it difficult for women to access LARCs in particular. LARCs can be expensive in the short term, and complicated billing and reimbursement practices in both public and private insurance confuse women and providers. Also, the full cost associated with LARC usage isn’t always covered by insurance.

But the process shouldn’t end at eliminating barriers. Low-income Black women and teens must receive comprehensive counseling for contraception to ensure informed choice—meaning they should be given information on the full array of methods. This will help them choose the method that best meets their needs, while also promoting reproductive autonomy—not a specific contraceptive method.

Clinical guidelines for contraception must include detailed information on informed consent, and choice and reproductive autonomy should be clearly outlined when family planning providers are trained.

It’s crucial we implement these changes now because recent investments and advocacy are expanding access to LARCs. States are thinking creatively about how to reduce unintended pregnancy and in turn reduce Medicaid costs through use of LARCs. The Colorado Family Planning Initiative has been heralded as one of the most effective in helping women access LARCs. Since 2008, more than 30,000 women in Colorado have chosen LARCs as the result of the program. Provider education, training, and contraceptive counseling have also been increased, and women can access LARCs at reduced costs.

The commitment to LARCs has apparently yielded major returns for Colorado. Between 2009 and 2013, the abortion rate among teenagers older than 15 in Colorado dropped by 42 percent. Additionally, the birth rate for young women eligible for Medicaid dropped—resulting in cost savings of up to an estimated $111 million in Medicaid-covered births. LARCs have been critical to these successes. Public-private partnerships have helped keep the program going since 2015, and states including Delaware and Iowa have followed suit in efforts to experience the same outcomes.

Recognizing that prevention is a key component to any strategy addressing a public health concern, those strategies must be rooted in ensuring access to education and comprehensive counseling so that women and teens can make the informed choices that are best for them. When women and girls are given the tools to empower themselves in decision making, the results are positive—not just for what the government spends or does not spend on social programs, but also for the greater good of all of us.

The history of coercion undermining reproductive freedom among women and girls of color in this country is an ugly one. But this certainly doesn’t have to dictate how we move forward.

Commentary Contraception

The Double Standard of Military Pregnancy: What Contraceptive Access Won’t Fix

Stephanie Russell-Kraft

Unique military gender politics that make it hard for some servicewomen to ask for birth control also stigmatize them if they get pregnant—especially when that happens at an overseas post or on a deployment. Any effort to increase birth control availability can only be understood against that particular cultural backdrop.

At the beginning of May, pharmaceutical giant Allergan announced that, in partnership with nonprofit Medicines360, it would begin offering its new intrauterine device (IUD) Liletta at a reduced price to military treatment facilities and veterans hospitals across the United States. The company would also support “an educational effort to raise contraception awareness among healthcare providers treating U.S. military service women,” according to its press release.

Military personnel and medical professionals agree Allergan’s initiative represents an important step toward expanding access to the IUD, which along with other long-acting reversible contraceptives (like injections) are particularly well suited to the demands of military training and deployment schedules. But this push to increase IUD use can’t be fully understood outside the context of the unique challenges and stigmas facing women of reproductive age in the U.S. military (who numbered just under 200,000 as of 2011, the latest available data obtained via FOIA by Ibis Reproductive Health).

Despite theoretically having access to a wide variety of contraceptive options, women in the military still report higher rates of unplanned pregnancy than their civilian peers, and it remains somewhat of a mystery exactly why. What is clear is that the unique military gender politics that make it hard for some women to ask for birth control also stigmatize them if they get pregnant—especially when that happens at an overseas post or on a deployment. Any effort to increase birth control availability, including Allergan’s, can only be understood against that particular cultural backdrop.

Nearly every time a U.S. military branch changes policies to include more women, critics raise the old argument that allowing women into the service, particularly in combat roles, will lead to sex between soldiers and thereby distract from the mission. Because of that, the military generally prohibits sex during deployments between service members not married to each other (exact policies vary across the branches and across units, and some are less strict). Taken as a whole, the U.S. military’s policy basically amounts to an abstinence-only approach, with women shouldering nearly all of the risk and blame when soldiers do decide to have sex on deployment.

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Bethany Saros, who enlisted in the Army as an 18-year-old in 2002, faced this blame head-on when she became pregnant by a fellow soldier during a 2007 tour in Iraq.

Although condoms were available to soldiers at her deployment site, Saros did not use birth control. Her decision not to end the pregnancy meant her deployment was over, and Saros recalls meeting several other pregnant women in Kuwait while they all waited to get shipped back. “I felt like a pariah, and I think the other girls did too,” she said.

“It’s not like anyone does this on purpose,” Saros explained. “The fathers of these babies, they don’t get any problems, and they were screwing around just as we were.”

Across all branches of service, pregnant women are typically not allowed to serve on deployments, and, though the length of time varies by branch, women are not allowed to deploy in the six to 12 months after they give birth. According to spokespeople from each of the branches, the reasoning behind the policies is to protect servicewomen and give them the time they need to recover from birth. All of the women I spoke with for this piece told me that soldiers—both male and female—often believe a woman who gets pregnant right before or during a deployment is simply trying to avoid her work.

“The first thing someone talked about when a woman got pregnant was that she was trying to get out of a deployment,” said Lauren Zapf, a former Naval officer, mental health clinician, and fellow with the Service Women’s Action Network. “Whereas if men announce that they’re going to have a baby, there’s a lot of backslapping and congratulations.”

According to Ibis Reproductive Health’s analysis of Department of Defense data, about 11 percent of active-duty military women reported an unintended pregnancy in 2008 and 7 percent reported an unintended pregnancy in 2011—in both years, this was far more than the general population. Younger, less educated, nonwhite women were much more likely to become pregnant unintentionally, as were those who were married or living with a partner, according to Ibis. Contrary to military lore, the pregnancy rates did not differ between those women who had deployed and those who didn’t during that time, the study found.

It remains unclear why exactly military women have higher reported rates of unplanned pregnancy than their civilian counterparts, but one reason has likely been their inconsistent access to birth control and limited access to abortion services. As with most institutions, there’s a difference between official policy and what happens on a day-to-day basis on military bases and in medical exam rooms. Just because most military branches officially require routine birth control consultations doesn’t mean women will always get them, according to Ibis researcher Kate Grindlay, who is one of very few independent researchers looking into this issue.

“One of the challenges that we found [in our research] was that these things were not being done in a consistent way,” Grindlay said. “Some providers having these conversations in a routine way, some weren’t.”

Access to birth control—and the conversations that lead up to it—has improved greatly for military women in the past 20 years. Elizabeth McCormick, a former Black Hawk pilot who served in the Army from 1994 to 2001, recalled that “no one talked about birth control” in any of her pre-deployment medical events in the 1990s. By contrast, some of the women I spoke with who served more recently said they didn’t have issues getting the care they needed.

However, in a 2010 Ibis survey of deployed women, 59 percent of respondents said they hadn’t discussed contraception with a military health-care provider before deployment and 41 percent said they had difficulty obtaining the birth control refills they needed while away from home. Servicewomen also reported being denied an IUD because they had not yet had children, even though nulliparous women can use the devices.

These inconsistencies are part of the problem Allergan says it hopes to address with its education efforts for military health-care providers. The company hasn’t explicitly said what those efforts will look like.

Another part of the problem, according to former Marine Corps officer and Cobra helicopter pilot Kyleanne Hunter, might be cultural. Conversations with military medical providers likely present another major barrier to proper contraceptive care because most military doctors are not only men, but also officers, who, outside the context of a hospital exam room, can give orders that must be respected.

Young female enlisted service members who have internalized the military’s rigid power structures might be reluctant to speak honestly and openly about reproductive care, posited Hunter, who’s currently a University of Denver PhD candidate studying the national security impact of integrating women into western militaries. She said the same dynamic often prevents women from coming forward after they have been sexually assaulted by a fellow service member.

“It adds one more layer to what’s already an uncomfortable conversation,” Hunter said.

When Bethany Saros returned to Fort Lewis, Washington, after leaving Iraq for her pregnancy, a conversation with a male doctor solidified her decision to quit the Army altogether.

“I had to go through a physical, and there was a Marine doctor, and he said, ‘Was there enough room on the plane for all the pregnant ladies that came back?’” she told me, still taken aback by the incident.

Grindlay said efforts like Allergan’s to increase the use of IUDs in the military are “very beneficial” to servicewomen. She also applauded a provision in the 2016 National Defense Authorization Act to require standardized clinical guidelines for contraceptive care across the armed forces. Under the new provisions, women in the armed forces must receive counseling on the “full range of methods of contraception provided by health care providers” during pre-deployment health care visits, visits during deployment, and annual physical exams.

But there’s still work to be done in order for the military to provide full access to reproductive health care, particularly when it comes to abortion. Tricare, the military’s health and insurance provider, only covers abortions “if pregnancy is the result of rape or incest or the mother’s life is at risk,” and certain countries in which the military operates ban the procedure altogether.

In a sampling of 130 online responses for a medication abortion consultation service reviewed by Ibis in 2011, several military women reported considered using “unsafe methods” to try to terminate a pregnancy themselves, according to Grindlay. One of the women, a 23-year-old stationed in Bahrain, said she had been turned away by five clinics and had contemplated taking “drastic measures.”

According to the 2011 Ibis report, many women sought abortions so that they could continue their military tour. Others feared a pregnancy would otherwise ruin their careers.

Virginia Koday, a former Marine Corps electronics technician who left the service in 2013, said in a phone interview that women can face losing their rank or getting charged for violating military policy if they become pregnant overseas. “Getting pregnant in Afghanistan is good cause to terminate your own pregnancy without anyone finding out,” she said.

“The unspoken code is that a good soldier will have an abortion, continue the mission, and get some sympathy because she chose duty over motherhood,” wrote Bethany Saros in a 2011 Salon piece about her unplanned pregnancy.

For these women, one act of unprotected sex had the potential to derail their career. For the men, it was just a night of fun.

Kyleanne Hunter said that while she doesn’t have a “whole lot of sympathy” for women who become pregnant on deployments (they’re not supposed to be having sex in the first place, she argues), she disagrees with the double standard that allows the men involved to escape punishment.

“Both parties need to be held exactly to the same accountability standards,” said Hunter. “If the woman is punished, then whoever she is involved with should be punished a well, because it takes two. She’s not alone in it. There’s no immaculate conception going on there.”

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