Strategies to Increase Access to Care

Many factors affect individuals’ ability to access contraceptive services. This section explores strategies that providers and systems can take to address the multilevel barriers that people encounter.

Extended contraceptive supply. Providers can prescribe a full year’s supply of combined hormonal methods at the time of the visit.94 This is 13 cycles (for example, pill pack, box of patches, rings) for those using hormone-free intervals, or 16 for those using combined hormonal contraception continuously. Although payers vary in how many cycles they reimburse for at a single fill, prescribing a full-year supply enables the patient to receive the maximum number possible.

Advance provision of emergency contraception pills (ECPs). Providers should offer patients an advance supply of ECPs to ensure that the ECPs will be immediately accessible when needed95, 96 A review of the evidence showed that advanced provision increases use of ECPs.96 There was no difference in contraceptive use, pregnancy rates, and incidence of STIs in those who received advanced provision and those that did not.96 Advance provision of ECPs should be coupled with counseling and education on proper use. Advance provision of ECPs is particularly important for expediting access to ulipristal acetate (UPA), which is more effective than levonorgestrel (LNG) ECP but available by prescription only. Although LNG ECP is available over the counter, some payers will not cover the cost without a prescription, so writing a prescription can reduce cost barriers for patients. When possible, it is preferable to provide pills directly to patients instead of writing a prescription, as patients may experience barriers to ECPs at pharmacies.95

When offering advance provision of ECPs, it can be helpful to also offer additional guidance on contraceptive initiation. People using LNG ECPs can start, continue, or resume any method immediately.96 People who receive an advance prescription for UPA should be advised that although it is more effective, it may interact with progestin-containing contraceptives, possibly lowering ECP effectiveness. People using UPA should therefore start or resume hormonal contraception no sooner than five days after using UPA.

If a patient wishes to use UPA and is initiating a progestin-containing method that is initiated in the clinical setting (such as DMPA, implant, or LNG IUD), a shared decision-making approach can be used to weigh the risk of reduced UPA effectiveness against the need to return for method initiation.

As described in the U.S. MEC and U.S. SPR, ECPs might be less effective among persons with BMI ≥30 kg/m2 than among persons with BMI <25 kg/m.2 ECPs are classified as U.S. MEC category 2 for persons with BMI ≥30 kg/m2, meaning the benefits outweigh the risks. Regardless of a person’s weight or BMI, all methods of EC can be offered, with complete counseling and clear information.93

Same-day access to contraception. When patients are asked to return at a later date to receive their selected contraceptive method, this creates a barrier to care and reduces the chance of the patient ultimately accessing their method.97, 98, 99 Logistic and administrative factors can create challenges to providing same-day contraception even when patients are clinically eligible and desiring to start a method. In particular, same-day provision of implants and IUDs can be difficult for some service sites to accommodate due to factors including provider availability, clinic flow, and insurance verification processes. To reduce this barrier, providers and administrators can work to implement clinical practices to facilitate the ability to offer same-day initiation of all contraceptive methods. Partners in Contraceptive Choice and Knowledge (PICCK) provides clinical and administrative resources for implementing same-day contraception. If, for any reason, a provider is unable to provide a patient’s method of choice on the same day that they request it, a bridge method should be offered. As part of standard practice, providers should support patients to access methods unavailable through their clinic by facilitating a warm hand-off or referral and offering information about where and how to access methods affordably. Clinics should keep a current list of local experienced providers that provide any services or methods not offered on-site.

Pharmacist-prescribed contraception. Many states permit pharmacists to directly prescribe hormonal contraceptives.100 This can enable people to access a range of contraceptive options without a separate visit to another provider to obtain a prescription. Providers should be aware of the pharmacist prescribing policies in their state, and, where available, inform patients of what may be available by pharmacist prescription.

Alternative locations. Mobile clinics, co-locating services, or offering services in temporary pop-up locations support access by meeting people where they are most comfortable receiving care. For example, research suggests co-locating contraceptive services with mental health or substance use disorder services can improve access to contraceptive care.101

Telehealth. Telehealth encompasses a wide range of services, including videoconferencing, telephone calls, remote patient monitoring, and secure messaging, which can occur in real time or asynchronously.102, 103 Most commonly, telehealth refers to providers using virtual platforms to communicate with and provide care to patients in lieu of—or in addition to—in-person visits. Research has found that telehealth for contraceptive care is acceptable to patients and providers and effective in delivering services, especially for people who wish to avoid a physical exam, reduce wait times, or have privacy concerns.103 A wide range of contraceptive services can be safely and effectively provided via telehealth, and telehealth can also be used for contraceptive counseling and management of side effects and other follow-up.104, 105 In addition, online platforms offer contraceptives to patients with and without insurance through online consultation, and ship methods directly to patients in unmarked packaging.

Contraceptive services that are suitable for telehealth provision include:106

• Contraceptive counseling
• Prescription (initiation or continuation) of oral contraceptive pills, transdermal patch, or vaginal ring 
• Discussion of EC options and provision of oral EC
• Prescription (initiation or continuation) and instruction on self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC)
• Prescription of barrier and other peri-coital methods (including diaphragm, cervical cap, spermicides, external and internal condoms, and vaginal pH modulator gel);
• Counseling prior to IUD and implant placement, removal, or replacement;
• Evaluation and potential management of side effects (such as unexpected bleeding)
• Consultation for permanent contraception