Meeting Summary: State and Local Implementation Strategies for Increasing Access to Contraception During Zika Preparedness and Response — United States, September 2016

Charlan D. Kroelinger, PhD; Lisa Romero, DrPH; Eva Lathrop, MD; Shanna Cox, MSPH; Isabel Morgan, MSPH; Meghan T. Frey, MA, MPH; Lee Warner, PhD; Kathryn M. Curtis, PhD; Karen Pazol, PhD; Wanda D. Barfield, MD; Dana Meaney-Delman, MD; Denise J. Jamieson, MD


Morbidity and Mortality Weekly Report. 2017;66(44):1230-1235. 

In This Article

Abstract and Introduction


Zika virus infection during pregnancy is a cause of microcephaly and other serious brain abnormalities.[1] To support state and territory response to the threat of Zika, CDC's Interim Zika Response Plan outlined activities for vector control; clinical management of exposed pregnant women and infants; targeted communication about Zika virus transmission among women and men of reproductive age; and primary prevention of Zika-related adverse pregnancy and birth outcomes by prevention of unintended pregnancies through increased access to contraception.* The most highly effective, reversible contraception includes intrauterine devices and implants, known as long-acting reversible contraception (LARC). On September 28, 2016, the Association of Maternal and Child Health Programs (AMCHP) and CDC facilitated a meeting in Atlanta, Georgia, of representatives from 15 states to identify state-led efforts to implement seven CDC-published strategies aimed at increasing access to contraception in the context of Zika virus.[2] Qualitative data were collected from participating jurisdictions. The number of states reporting implementation of each strategy ranged from four to 11. Participants identified numerous challenges, particularly for strategies implemented less frequently. Examples of barriers were discussed and presented with corresponding approaches to address each barrier. Addressing these barriers could facilitate increased access to contraception, which might decrease the number of unintended pregnancies affected by Zika virus.

Twenty-six participants representing 15 states and 11 local health departments and clinics§ were selected to attend the Atlanta meeting, based on successful implementation of at least two of the seven strategies for increasing access to contraception (Table 1). AMCHP conducted a premeeting web-based assessment among attendees on the use of specific approaches for implementing the seven strategies. Responses to the assessment represented 12 states, including 12 state-level participants and six local-level participants and service providers. During the in-person meeting, participants discussed the premeeting assessment responses and identified approaches to addressing barriers and maximizing facilitators for increasing access to contraception in three AMCHP-facilitated discussion sessions. Representatives from federal agencies and maternal and child health (MCH) organizations participated and provided technical and scientific expertise.** CDC analyzed qualitative data[3] to identify state implementation approaches (Table 2) that addressed barriers to and facilitators of success for the seven strategies.

Strategy 1. Facilitate Partnerships Among Insurers, Manufacturers, and State Agencies

Respondents from eight of 12 states indicated that their state health agencies partnered to implement a direct payment program to absorb contraceptive device acquisition and stocking costs, develop pharmacy contracts to obtain devices, bill insurers directly for devices, or offer an option to return unused or unopened devices (Table 1). Personnel turnover and limited understanding of the internal organization and structure of other agencies were identified as barriers to developing contracts with payers and manufacturers (Table 2). Leaders with successful external partnerships leveraged current health department structures to institutionalize interagency partnerships and implement public-private partnerships to address these barriers.

Strategy 2. Reimburse Providers for the Full Range of Contraceptive Services

Seven of 12 states implemented policies to reimburse providers for the actual cost of LARC devices and eliminate barriers in state payment plans for LARC prescriptions (Table 1). States described implementing a payment policy for immediate postpartum LARC supplies, procedures, and follow-up, using prestocked kits. States discussed payment policies to reimburse providers for pregnancy intention screening and client-centered contraceptive counseling. Successful approaches to overcoming payment barriers included leveraging health department support in developing immediate postpartum LARC policies that reimburse for the device costs, insertion fees, and training of mid-level providers on contraceptive counseling (Table 2).

Strategy 3. Remove Logistic and Administrative Barriers for Contraceptive Services and Supplies

Nine of 12 states implemented approaches to eliminate requirements for prior authorization, multiple visits, and step therapy†† approaches (Table 1). State-reported successful implementation approaches included training of billers and coders on reimbursement procedures, leveraging existing billing mechanisms (e.g., 340B pricing§§), eliminating requirements for multiple visits to facilitate same-day insertion, removing barriers for vulnerable or targeted populations, and engaging provider champions¶¶ to influence provision of services (Table 2).

Strategy 4. Train Health Care Providers on Current Insertion and Removal Techniques for LARC, Using Evidence-based Guidance

Ten of 12 states described integrating evidence-based contraceptive guidance into state family planning guidelines, collecting data on the use of the most effective or moderately effective*** Food and Drug Administration (FDA)-approved contraceptive methods, and providing resources to dispel common provider misperceptions about LARC (Table 1). Successful approaches to initiating statewide training efforts included statewide service assessment and continuing training of providers on the newest evidence-based techniques (Table 2).

Strategy 5. Support Youth-friendly Reproductive Health Services

Most (11 of 12) states provided teen-focused, culturally appropriate materials, offered training to providers on the provision of youth-friendly services, encouraged expanded availability of youth-friendly reproductive health services, and ensured that confidentiality concerns of adolescents were addressed in state or clinic policies (Table 1). Meeting participants indicated that a successful implementation approach for this strategy included soliciting youth feedback on services through youth advisory boards, social media, and youth mystery shoppers††† at service sites (Table 2). Additional approaches include ensuring adolescent confidentiality among payers and insurers and appropriate screening and counseling for this age group.

Strategy 6. Engage Smaller or Rural Facilities, Including Community Health Centers

Nine of 12 states provided funding to smaller or rural health care facilities and clinics, and targeted resources for LARC at these facilities (Table 1). Approaches to addressing barriers included training staff on billing and coding procedures, and funding subsidies in small or rural clinics for the client encounter, counseling, device cost, and insertion fees (Table 2).

Strategy 7. Assess Client Satisfaction With Service Provision and Increase Consumer Awareness

Four of 12 states provided resources to assess client satisfaction with the chosen contraceptive method or engaged in health promotion campaigns to increase consumer awareness about highly effective, reversible methods (Table 1). Implementation approaches included developing assessment measures that differentiated between client satisfaction and client experience, and collaborating with nontraditional partners (including supermarket chains, retail outlets, or airports) to expand the reach of contraceptive messaging (Table 2). Meeting participants highlighted limited funding for state-level social media or traditional media campaigns as the greatest barrier to implementation. Use of consumer awareness media campaigns with nontraditional partners was discussed for the dissemination of prevention messaging during a public health emergency, particularly in the context of Zika preparedness. For example, partnering of the state health department with international airports to include Zika virus travel-related guidance from CDC was noted as an effective strategy for Zika preparedness messaging that could also include information on contraception access.

Highly effective contraceptive methods result in a low pregnancy rate (i.e., fewer than one in 100 women using these methods will become pregnant during the first year of typical use).
§A total of 15 state-level participants represented Colorado, Delaware, Georgia, Florida, Iowa, Louisiana, South Carolina, Tennessee, Texas, and Washington. There was one representative for each state health department, with Colorado, Florida, Iowa, Louisiana, and Texas having two state-level representatives. A total of 11 local-level participants represented urban areas and/or clinics in Arizona, Colorado, Florida, Georgia, Nebraska, New Mexico, New York, Texas, Washington, and Wisconsin. There was one representative for each local jurisdiction, with Colorado having two local-level representatives.
A total of 12 states were represented in responses, including Arizona, Colorado, Delaware, Florida, Iowa, Louisiana, Nebraska, New York, South Carolina, Texas, Washington, and Wisconsin. Each state had one response, except three responses were received from Florida, and two responses each were received from Colorado, Iowa, Texas, and Washington, for a total of 18 responses overall. All respondents were state-level personnel except those from Washington, which included personnel at the state and local levels. Georgia, New Mexico, and Tennessee did not provide responses to the premeeting assessment.
**Participating federal agencies include CDC, Centers for Medicaid and Children's Health Insurance Plan Services/Centers for Medicare and Medicaid Services, Bureau of Primary Health Care/Health Resources and Services Administration, Food and Drug Administration, and Office of Population Affairs. Participating MCH organizations included AMCHP, American College of Obstetricians and Gynecologists, Association of State and Territorial Health Officials, CityMatCH, March of Dimes, National Family Planning and Reproductive Health Association, and National Association of City and County Health Officials.
††Step therapy is a type of prior authorization requiring that prescriptions be filled with the most cost-effective drug therapy (i.e., generic) progressing to more costly or risky drug therapies as necessary. The generic drug options for long-acting reversible contraception (LARC) are limited.
§§340B pricing is a discount drug program that requires drug manufacturers to provide outpatient drugs to eligible health care organizations/covered entities at significantly reduced prices.
¶¶Provider champions are persons who dedicate themselves to overcoming resistance or indifference to a beneficial intervention by supporting, publicizing, and implementing strategies to bridge the gap between knowledge and clinical practice.
***Moderately effective contraceptive methods include injectables, pills, patch, ring, and diaphragm. Approximately six to 12 per 100 women using these methods will become pregnant during the first year of typical use.
†††Youth mystery shoppers for contraceptive services are adolescents hired by an organization or agency (health department) to visit clinics posing as new patients to collect information on clinic flow, resources provided, and the quality of interaction with clinic personnel and providers.