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Advancing Contraceptive Care to Improve Maternal Health Outcomes

September 30, 2024 | Brittany Lee, Sophia Durant

Contraceptive care is a critical component of maternal health. This toolkit provides an overview of contraceptive care, explores its impact on maternal health outcomes, and offers strategies to advance access to contraceptive services. Additionally, it highlights successful state initiatives that have improved maternal health outcomes by increasing access to contraceptive care.

Introduction

Contraceptive care plays a crucial role in improving maternal health outcomes in the United States by offering individuals the means to plan and space pregnancies, ultimately contributing to healthier pregnancies and birth outcomes, and reducing maternal mortality rates. Most notably, contraceptive care:

Prevents unintended pregnancies and sexually transmitted infections (STIs).
Promotes healthy birth spacing.
Reduces maternal mortality.
Enhances access to prenatal care.
Improves socioeconomic outcomes.
Empowers women.
Improves health disparities.

Ensuring widespread access to comprehensive contraceptive care is essential for promoting the well-being of mothers and contributing to overall public health.

Academic institutions and government agencies put forth the data within this toolkit. These institutions largely use language that reflects a gender binary (i.e., girls/women/mothers vs. boys/men/fathers). The use of these terms in this toolkit is not meant to reinforce that binary but rather to remain consistent with language in the referenced research.

How to Use This Toolkit

This toolkit is intended to guide state and territorial health agencies in understanding and advancing contraceptive care access in their jurisdictions to, in turn, advance maternal health outcomes. This toolkit can be used by state health agency staff and their partners to inform policy and programmatic work in both sexual and reproductive health and maternal infant health spaces.

Contraceptive Care Components: This section defines contraceptive care and its key components: education and counseling, birth control methods, access to contraceptives, and respect for reproductive autonomy and promoting reproductive justice.
Impact of Contraceptive Care on Maternal Health Outcomes: This section discusses key contraceptive care levers that impact maternal health outcomes such as preventing unintended pregnancies and sexually transmitted infections (STIs), promoting healthy birth spacing, and enhancing access to prenatal care.
Strategies to Advance Access to Contraceptive Care: This section highlights four key strategies to leverage contraceptive care to improve maternal health outcomes: Medicaid family planning State Plan Amendments (SPAs) and waivers, extended postpartum Medicaid coverage, increased contraceptive counseling in the prenatal period, and immediate postpartum long-acting reversible contraceptives (LARCs).

Contraceptive Care Components

Contraceptive care refers to the range of medical services and interventions aimed at preventing unintended pregnancies.

In 2019, 41.6% of pregnancies in the United States were unintended.

Education and Counseling

Healthcare providers offer information about different contraceptive methods, their effectiveness, potential side effects, and how to use them correctly. Counseling should be patient-centered and trauma-informed, with the provider and patient exploring an individual's reproductive goals and working together to choose a method that aligns with their preferences and health needs.

Contraceptive Methods

There are various contraceptive methods available, including hormonal methods (e.g., birth control pills, patches, injections, and implants), barrier methods (e.g., condoms and diaphragms), long-acting reversible contraception (e.g., intrauterine devices and implants), sterilization procedures, and fertility awareness methods. Each method has its own benefits, drawbacks, and considerations. Condoms are the only contraceptive method, apart from abstinence, that prevents the transmission of STIs. Contraceptive care may involve providing emergency contraception for individuals who have had unprotected sex or experienced contraceptive failure.

Access to Contraceptives

Contraceptive care also involves ensuring that individuals have access to a range of contraceptive methods. Some populations, such as those with limited access to the healthcare system due to geography, income, or fear and distrust in the medical system, experience additional barriers accessing contraceptive care (e.g., transportation, time off of work, and childcare needed for an individual to get to their provider and/or pharmacy to access the contraceptive method of choice), which can significantly impact continuation or appropriate utilization of contraception. Contraceptives are often time-sensitive medications or devices, and, when access is limited, can result in unintended pregnancies.

In 2023, one study found that 45% of women experienced at least one challenge in accessing contraception in the past year.

Strategies to increase access to contraception may include making all contraceptives available at healthcare facilities the same day, increasing access to pharmacist-prescribed contraception models, making hormonal contraception available over the counter (such as Opill), and increasing use of telemedicine for contraceptive care.

Respect for Reproductive Autonomy and Promotion of Reproductive Justice

A fundamental aspect of contraceptive care is respecting an individual's autonomy in making decisions about their reproductive health. This includes considering personal, cultural, and religious beliefs in the choice of contraceptive methods. “Reproductive justice” encompasses these aspects, which SisterSong defines as the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.

Contraceptive care is an essential component of reproductive healthcare, supporting individuals and couples in making informed choices to achieve their family planning goals while promoting overall well-being. Trained professionals, including doctors, nurses, midwives, community health workers, and family planning specialists, typically provide this service.

Impact of Contraceptive Care on Maternal Health Outcomes

Preventing Unintended Pregnancies

Contraceptive care empowers individuals, couples, and families to make informed choices about family planning, helping to prevent unintended pregnancies. This is particularly significant in reducing the risks associated with unplanned pregnancies, such as delayed prenatal care and increased likelihood of complications during childbirth.

Preventing STI Transmission

STIs, also called sexually transmitted diseases (STDs), are infections that can be passed between partners during sexual contact. Condoms are the most common way to prevent transmission of STIs between partners. Most STIs are curable, and all are treatable.

About 1 in 5 people in the United States have an STI. If left untreated, STIs can permanently impact a person’s health, including leading to complications such as ectopic pregnancy and infertility. Untreated STIs in pregnancy can cause premature labor and stillbirths, and some can be passed from parent to baby, which can impact the baby’s birth weight and cause other health problems such as infections and brain damage.

Congenital Syphilis

Syphilis is an STI caused by bacteria; congenital syphilis is when a pregnant person with syphilis transmits the infection to the baby during pregnancy or childbirth. Congenital syphilis is increasing in the United States and can cause major health problems for both the pregnant person and baby. All pregnant people should test for syphilis early in their pregnancy, during the third trimester, and at delivery to prevent health complications.

Promoting Healthy Birth Spacing

Research suggests that a shorter amount of time between births can have negative maternal and infant health outcomes. Adequate spacing between pregnancies is vital for maternal health. Contraceptive methods allow women to plan the timing of their pregnancies, reducing the health risks associated with pregnancies that are too closely spaced. Optimal birth spacing (i.e., waiting at least 18 months between giving birth and becoming pregnant again) supports healthier outcomes for both mothers and infants.

Reducing Maternal Mortality

Timely access to contraceptive care can help reduce maternal mortality by preventing high-risk pregnancies and ensuring that women can attain the best possible health before becoming pregnant. This is particularly important for women with pre-existing health conditions.

Enhancing Access to Prenatal Care

Contraceptive care enables women to plan pregnancies when they are emotionally and physically prepared, increasing the likelihood of early and consistent prenatal care. Regular prenatal check-ups are critical for monitoring the health of both the mother and the developing baby, reducing the risk of complications.

Improving Socioeconomic Outcomes

Contraceptive care can have broader societal impacts by allowing individuals and couples to plan their families in a way that aligns with their educational and career goals. This can contribute to improved socioeconomic outcomes, which in turn positively influence maternal health.

Advancing Reproductive Autonomy

Access to contraceptive care empowers women to take control of their reproductive health, fostering autonomy and decision-making. This empowerment contributes to overall well-being, as women can choose if and when to start a family, enabling them to pursue education and career opportunities.

Addressing Health Disparities

Inequities in access to contraceptive care persist—for example, individuals living in rural areas are more likely to need publicly funded contraceptive care. Ensuring that all individuals, regardless of socio-economic status or geographic location, have equitable access to family planning resources helps mitigate disparities in maternal health outcomes.

Strategies to Advance Access to Contraceptive Care

Medicaid Family Planning State Plan Amendments (SPAs) and waivers play a pivotal role in enhancing access to contraceptive care, thereby contributing to improved reproductive health outcomes. When CMS approves a family planning SPA, the Medicaid state plan is permanently amended to allow the state to receive federal dollars for the changes outlined in the approved SPA. When CMS approves a family planning Section 1115 waiver, the state receives temporary approval to receive federal dollars for the changes outlined in the waiver.

By incorporating SPAs and waivers, states can tailor their Medicaid programs to address the unique needs of their populations, increasing access to contraceptive services, counseling, and education. This enables Medicaid beneficiaries to make informed choices about family planning, fostering better health outcomes and reducing unintended pregnancies. Medicaid SPAs and waivers serve as crucial mechanisms in advancing equitable access to comprehensive contraceptive care, aligning with broader public health goals, and promoting the well-being of diverse communities.

Several states have implemented Medicaid family planning SPAs and waivers to enhance contraceptive care outcomes. For instance, states like California, New York, and Louisiana have utilized these mechanisms to broaden the scope of Medicaid coverage and extend family planning services to a larger demographic. Specifically, states have done this by increasing the income eligibility threshold and expanding eligibility to men. These initiatives often include coverage for a range of contraceptive methods and counseling services. The aforementioned states reported that incorporating family planning SPAs and waivers resulted in higher contraceptive uptake, lower rates of unintended pregnancies, and improved maternal and child health. These state Medicaid policy mechanisms allow states to adapt their programs to local needs, fostering innovation in the delivery of contraceptive care, and ultimately contributing to more effective and accessible reproductive healthcare services.

Extended Postpartum Medicaid Coverage plays a pivotal role in bolstering contraceptive access for women in the critical postpartum period. Extended postpartum Medicaid coverage continues Medicaid coverage of the pregnant person for a longer amount of time after the pregnancy ends. Historically, pregnant people were only covered for 60 days after a pregnancy ended, but with extended coverage, some states allow people to keep their Medicaid coverage for a longer period, sometimes up to a year.

This policy initiative ensures that those who are pregnant, especially those facing economic challenges, have continued access to a spectrum of contraceptive options after a pregnancy ends. This extended coverage addresses a vulnerable time when pregnant people may experience gaps in healthcare access and provides a vital opportunity for them to receive counseling and obtain contraceptives suited to their individual needs. Additionally, increased access to health coverage during the postpartum period can help connect patients with other vital healthcare services via safety net providers to address healthcare concerns such as hypertensions, diabetes, and mental health, further improving health outcomes.

By removing financial barriers, this policy promotes consistent and effective contraceptive use, allowing pregnant people to exercise greater control over their reproductive health. This targeted approach reduces unintended pregnancies, empowering people to make informed choices about family planning during a period of heightened vulnerability, ultimately contributing to improved maternal and child health outcomes. The majority of states have implemented Extended Postpartum Medicaid Coverage to address the gaps in reproductive healthcare and enhance contraceptive access for women beyond the standard 60-day postpartum period, including:

California: California expanded its Medi-Cal program, providing coverage for family planning services for low-income individuals beyond the initial postpartum weeks. This extension means an increased uptake of long-acting reversible contraceptives and improved birth spacing, contributing to a decline in unintended pregnancies.
Texas: Texas expanded its postpartum Medicaid and Children’s Health Insurance Program (CHIP) coverage to 12 months, effective as of March 1, 2024. Texas used data from the COVID-19 public health emergency’s continuous coverage requirement to examine the impact of extended coverage during the postpartum period. One organization found that women continuously enrolled utilized more contraceptive services and had fewer services for subsequent pregnancies during their first year postpartum.

Increased contraceptive counseling during the prenatal period plays a pivotal role in empowering expectant parents with the knowledge and tools to make informed decisions about family planning. This counseling serves as a valuable opportunity for healthcare providers to engage with pregnant individuals and their partners, discussing various contraceptive options, addressing concerns, and tailoring recommendations to align with the unique needs of the individual.

State health agencies can work with Medicaid agency partners to implement Medicaid quality measures, such as the Prenatal and Postpartum Care CMS Core Measure (NQF #1517) and the Contraceptive Care for Postpartum Women Ages 15-20 and Ages 21-44 measures (NQF #2902), to incentivize providers to provide contraceptive counseling during prenatal and postpartum care. States can create explicit details on the practice guidelines for contraceptive counseling during this period.

This proactive approach not only facilitates informed decision-making but also contributes to the overall well-being of the family unit by promoting reproductive autonomy and allowing individuals to plan their families in a manner that aligns with their life goals and circumstances. Ultimately, increased contraceptive counseling in the prenatal period contributes to reductions in unintended pregnancies, which is associated with reductions in maternal mortality and morbidity, and improved newborn health.

Access to immediate postpartum long-acting reversible contraception (IPP-LARC), encompassing intrauterine devices or contraceptive implants, is a critical component in advancing maternal health outcomes.

Research underscores that women who choose immediate postpartum LARC experience a substantial reduction in unintended pregnancies during the first year postpartum compared to those relying on traditional contraceptive methods. This intervention not only mitigates health risks associated with closely spaced births but also helps bridge the gap between hospital discharge and the initiation of a reliable contraceptive method, reducing the likelihood of unintended pregnancies. By empowering women to make timely and informed choices about family planning, client-centered immediate postpartum LARC contributes to enhanced reproductive autonomy, optimal birth spacing, and improved maternal well-being, aligning with broader public health objectives.

State Medicaid agencies can make policy changes specific to reimbursement for IPP-LARC to support providers and hospital systems in offering this service. These policy changes focus on carving out the cost of the LARC device and insertion of the device from the global labor and delivery payment.

Success Stories

New Jersey’s Nurture NJ Initiative

In 2018, New Jersey was ranked 47th in the United States for maternal and infant mortality, and the state had one of the widest disparities for maternal and infant mortality.

In New Jersey in 2018, a Black mother was almost seven times more likely to die from pregnancy-related complications than a white mother, and a Black baby was three times more likely than a white baby to die before their first birthday.

Seeing these disparities, New Jersey’s first lady, Tammy Murphy, launched the Nurture NJ initiative in 2019. Nurture NJ is a statewide initiative aimed at reducing maternal and infant mortality and morbidity, promoting equitable care, and improving collaboration and programming surrounding maternal and infant health.

Convening a multidisciplinary steering committee, Nurture NJ spent a year reviewing scientific evidence, developing an ecosystem map, and understanding what current initiatives, agencies, and organizations do work within spaces that impact maternal and infant health.

Through interviews with officials, stakeholders, and groups of mothers, Nurture NJ drafted a strategic plan with nine action areas to improve maternal and infant health. Each action area contains specific, actionable recommendations that seamlessly weave interdisciplinary components impacting maternal and infant health together. One action area is to strengthen and expand public policy to support conditions for health in New Jersey, which include specific recommendations around safe affordable housing, improving access to high quality education, paid family leave, and expanding flexibility in Supplemental Nutrition Assistance Program.

Integrated within these action areas are specific recommendations around family planning services and contraception access. For example, one action area is to change institutional structures to accommodate innovation and transformative measures, which include specific recommendations to increase funding for prenatal and reproductive healthcare for undocumented women as well as provide access to the full range of family planning services.

Additional actionable strategies around family planning include the following:

Affirmatively provide comprehensive family planning services and reproductive autonomy through policy and funding.
Ensure funding of the state family planning program continues and expand the safety net of family planning availability for all individuals in all communities.
Consider payment changes to ensure that women will have access to the full range of family planning options.
Provide access to the full range of family planning services, including all safe and effective contraception methods and abortion care through stronger provider relationships.
Work to integrate family planning providers into the rest of the maternal healthcare system.
Disseminate the New Jersey Reproductive Health Access Project’s Provider Access Commitment Toolkit to ensure providers are offering the full range of contraceptive options.

Over the past few years, New Jersey has seen significant improvements in its maternal and child health indicators, with most recent data ranking New Jersey 27^th for maternal mortality, a significant improvement from their previous ranking as 47^th. However, racial disparities still exist in maternal health outcomes in the state, indicating a critical area for continued improvement.

Numerous pieces of legislation have passed since 2019 aimed at improving maternal and infant health, including increased funding for family planning services, as well as the creation of the Plan First initiative which is a limited benefit insurance program providing the full range of family planning services to people without insurance. As indicated previously, many of the recommendations in place for New Jersey focus on increasing access to contraceptive care, while also prioritizing patient-centered care and increased training for healthcare providers to improve health outcomes, promoting reproductive autonomy, and reducing reproductive coercion.

As of July 2023, the Nurture NJ initiative helped establish the New Jersey Maternal and Infant Health Innovation Center, which will support research and data collaboration around maternal and infant health, serve as a workforce training center, and offer clinical services for mothers and infants.

North Carolina’s Perinatal Health Strategic Plan (PHSP)

North Carolina first implemented a perinatal health strategic plan (PHSP) in 2016 with the goals of improving healthcare, strengthening families and communities, and addressing social and economic inequities. While the first PHSP helped build statewide initiatives and partnerships and helped improve some health outcomes (e.g., the infant mortality rate in North Carolina decreased), other health outcomes worsened (e.g., the preterm birth rate increased).

North Carolina’s 2022-2026 PHSP builds on the first plan’s goals to "improve maternal and infant health and the health of all people of reproductive age." However, the 2022-2026 PHSP contains two key differences: engagement with the perinatal health equity collective and a monitoring plan. The perinatal health equity collective is a group made up of over 200 interdisciplinary stakeholders invested in improving maternal and infant health outcomes in North Carolina. The collective helped create the 2022-2026 PHSP and advocates for policies and programs outlined in the PHSP. Additionally, the 2022-2026 PHSP integrates key data indicators within each goal and subgoals to help monitor the plan’s impact. By incorporating data metrics into each goal, the 2022-2026 PHSP builds actionable, interdisciplinary strategies to improve maternal and infant health.

Although called a perinatal health strategic plan, North Carolina recognizes the interconnected nature of health, incorporating social determinants of health into the plan, while expanding the plan’s reach to include all people of reproductive age. Within each goal contains “points” or subgoals, each of which contain interdisciplinary and measurable strategies that contribute to achieving the larger goal. Under the goal of addressing economic and social inequities, one point is to support working parents and families. Related strategies include passing legislation to provide paid family medical leave, earned paid sick leave, increase accessibility to childcare, strengthening policies that support breastfeeding in the workplace and reasonable pregnancy accommodations.

Integrated within these points are specific recommendations around family planning services and contraception access. Actionable strategies around family planning include the following:

Increasing access to evidence-based reproductive health education.
Providing support for pregnant and parenting teens.
Providing reproductive life planning and reproductive justice training to clinic and school staff.
Utilizing adolescent well visits for confidential conversations about reproductive health.
Integrating preconception and reproductive health in health education programs at schools, universities, and adult learning programs.
Increasing the number of programs that offer information to adolescents about reproductive health and healthy relationships.
Eliminating coercion and bias from contraceptive access.
Implementing the Be Smart Family Planning Medicaid Strategic Plan.
Increasing access to reproductive life planning and referrals to resources.
Implementing an educational campaign to increase testing and treatment for STIs.
Increasing same-day access to all methods of contraception.