Texas turns to IUDs to curb unintended pregnancy

Peggy Wall, a family nurse practitioner at an Austin community health center, treats many women in their 40s, who already have a family and find themselves confronting an accidental pregnancy.

Many, she says, wish they had taken preventive steps after their last child was born and could be good candidates for getting an intrauterine device in the delivery room immediately after giving birth. Until recently, that sort of IUD access has been difficult to come by.

“Some of them have chaotic lives – or they think they won’t be insured,” she said. “We try to help them.”

Soon, she said, that should become easier.

Health officials are trying to rebuild the state’s women’s health program, a complicated project launched after Texas in 2011 cut funds for family planning that had been going to Planned Parenthood and other clinics affiliated — even loosely — with abortion providers. As part of the new program, the state is trying to bolster low-income women’s access to birth control to curb unintended pregnancies.

Nationally, about half of pregnancies are unintended. And Texas is one of nearly two dozen states changing their Medicaid programs, the federal-state insurance plan for the disabled, poor children and the lowest-income people, to pay hospitals for inserting an IUD or contraceptive implant in the delivery room. In the past, most Medicaid programs generally offered a set payment for labor and delivery and didn’t include an option for payment for the IUD insertion.

States hope to keep women healthier, especially since doctors advise spacing pregnancies at least 18 months apart. They’re betting the upfront investment will pay off.

So far, 20 states plus the District of Columbia are promoting the option, while others such as Oregon, Pennsylvania and Tennessee are considering it. The federal Centers for Medicare & Medicaid Services this spring began urging states to adopt the payment practice. The Centers for Disease Control and Prevention has singled out immediate post-partum insertion of long acting birth control as key to curbing unintended pregnancy. Organizations such as the American College of Obstetricians and Gynecologists (ACOG) and the Association for State and Territorial Health Officers are also on board.

“It just makes so much sense – from a patient-care standpoint and from a dollars standpoint,” said Melissa Gerber, president of AccessMatters, a Pennsylvania-based organization advocating for  the change there.

Only recently have IUDs, which are reversible and 99 percent effective, come into vogue among public health experts. But the high price tag has kept many people from using the devices, which can cost nearly $1,000 upfront even though hormonal ones last for up to six years. Many patients and doctors also remain skittish because of residual fear after the Dalkon Shield caused health problems for many women in the 1970s. That’s one of the reasons why many doctors never learned to insert the devices or counsel patients about them, even though current versions of the device don’t bring those same health risks.

Younger OB/GYNs are more likely to be familiar with IUDs, but even they often aren’t fluent in the post-labor procedure, which is done as soon as 10 minutes after delivery. It isn’t difficult, experts said, but is different.

Until recently, doctors usually waited to discuss an IUD or implant until a woman’s first postnatal checkup, six weeks after delivery. But between 10 percent and 40 percent of women never show up for this exam. In Travis County, which includes Austin, it’s more like 60 percent for women on Medicaid, estimated Ted Held, director of reproductive health at People’s Community Clinic. That is why the delivery room option is viewed by many as an opportunity.

But for this approach to have an impact, local governments, hospitals and doctors all need to make extra effort. That means training doctors, adapting hospital infrastructures and ensuring patients get proper counseling – so that they get the contraception treatment only if they want it and can have a device removed if they change their mind.

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