title: Funding policies and postabortion long-acting reversible contraception: results from a cluster randomized trial.
abstract: BACKGROUND
  Almost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting.
  
  
  OBJECTIVE
  We conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion.
  
  
  METHODS
  This subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year.
  
  
  RESULTS
  Women who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43).
  
  
  CONCLUSIONS
  The clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA. Electronic address: corinne.rocca@ucsf.edu.
authors.forename: Corinne H
authors.initials: CH
authors.lastname: Rocca
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA.
authors.forename: Kirsten M J
authors.initials: KM
authors.lastname: Thompson
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA.
authors.forename: Suzan
authors.initials: S
authors.lastname: Goodman
authors.affiliation: Planned Parenthood Federation of America and the Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
authors.forename: Carolyn L
authors.initials: CL
authors.lastname: Westhoff
authors.affiliation: Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, CA.
authors.forename: Cynthia C
authors.initials: CC
authors.lastname: Harper
mesh_terms: D000028:Abortion, Induced / Q000191:economics* / Q000706:statistics & numerical data; D000293:Adolescent; D000328:Adult; D000554:Ambulatory Care Facilities; D003268:Contraception Behavior / Q000706:statistics & numerical data*; D003274:Contraceptive Devices, Female / Q000191:economics / Q000706:statistics & numerical data*; D003376:Counseling / Q000706:statistics & numerical data; D005260:Female; D006291:Health Policy; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D008483:Medical Assistance; D011247:Pregnancy; D013219:State Government; D014481:United States; D055815:Young Adult
keywords: abortion; insurance; long-acting reversible contraceptive; policy; postabortion contraception