Long-acting reversible contraception access

Long-acting reversible contraceptives (LARCs) include intrauterine devices (IUDs) and implants that can prevent pregnancy for 3 to 10 years and can be removed at a woman’s discretion. LARCs are over 99% effective, a higher effectiveness rate than other birth control options (CDC-Contraception). LARCs can be used safely by teens and women regardless of whether they have previously given birth (ACOG-LARC 2017). Despite very few medical contraindications to LARC use (CDC-MEC 2016), a variety of barriers at the patient, provider, and systems level have limited access to and uptake of LARCs. LARCs can be made accessible through broad-based efforts to decrease patient costs such as ensuring that LARCs are available at low or no cost through Title X family planning sites and other sources of care, and ACA provisions requiring full coverage of birth control options. Efforts to increase access to LARCs can include provision of comprehensive contraceptive counseling on the full range of birth control options (including LARC) for all interested patients, provider training on LARC insertion and removal, and consistent availability of LARCs at local hospitals and clinics. Accessibility of LARCs could also be improved by elimination of medically unnecessary steps between request and insertion, including two visit protocols and STI testing prior to the day of insertion (). LARCs can be inserted and removed by many types of clinicians in a range of clinical settings, including primary care and non-traditional locations such as school-based health center or mobile van settings ().

Expected Beneficial Outcomes (Rated)

  • Increased use of contraception

  • Reduced teen pregnancy

  • Reduced unintended pregnancy

Evidence of Effectiveness

There is some evidence that increasing access to long-acting reversible contraceptives (LARCs) through efforts such as comprehensive contraceptive counseling and cost reduction increases uptake of LARCs and reduces unintended pregnancies (, Goyal 2017, Lindo 2017, , , ). LARCs are recommended as a safe and effective first-line choice of birth control for teens (ACOG-LARC 2017, ) and women (ACOG-LARC 2017). However, additional evidence is needed to confirm the effects of efforts to increase access to LARCs, without reducing the choices of vulnerable populations, and determine which intervention components have the greatest effect.

Interventions such as the Contraceptive CHOICE Project in St. Louis and the Colorado Family Planning Initiative that include both comprehensive contraceptive counseling and provision of no cost or discounted contraception, including LARCs, can increase uptake of LARCs (, Birgisson 2015, , ) and reduce unintended pregnancy among teens (, Lindo 2017, , , Peipert 2012) and adults (, ). An analysis of Colorado’s initiative suggests teen births decline most in the highest poverty areas (Lindo 2017). LARC use appears to increase when out-of-pocket expenses are low (, , ) or eliminated (Goyal 2017). An Iowa initiative suggests that increasing funding for family planning services for women with low incomes may also increase use of LARCs ().

Training providers to deliver broad-based counseling about birth control options and insert IUDs may increase counseling and LARC selection for all patients (, ), but may only increase LARC initiation and reduce pregnancy rates among patients who receive counseling at family planning visits (). For patients whose visits are not likely to be covered by insurance, studies suggest counseling alone increases LARC selection but not initiation (, ); initiation appears to be associated with sufficient insurance coverage (). 

Experts recommend programs working to ensure LARC access provide comprehensive counseling on all contraceptive methods, rather than promoting LARC use within specific groups, in order to avoid reproductive coercion of more vulnerable populations (NWHN 2017, Gomez 2015). This includes ensuring access to LARC removal when individuals choose, without barriers from provider resistance or insurance coverage (, NWHN 2017).

The Teen Options to Prevent Pregnancy (TOPP) program, aimed at reducing rapid repeat pregnancy in adolescents, increased the use of LARCs using a combination of motivational interviewing emphasizing highly effective contraceptive methods, transportation, and clinical services (). In Arizona, a clinic-based intervention for adolescents coming in for prenatal care that included prenatal contraceptive counseling delivered via motivational interviewing and emphasizing LARCs increased LARC uptake compared to standard prenatal care ().

The American College of Obstetricians and Gynecologists (ACOG) recommends same day, single visit LARC insertion, including postpartum (ACOG-642 2015). In a Texas-based study, LARC use was higher in the hospital that offered immediate postpartum LARC (Potter 2018), and a study in a Vermont clinic illustrates the barriers presented by a two visit protocol, as women with Medicaid were less likely to have LARCs inserted than women with private insurance (Higgins 2018).

Adding a social media component such as Facebook to standard contraceptive counseling may increase patients’ knowledge of contraceptives and use of LARCs (), though a campaign using only Facebook advertisements did not detect a change in the use of LARCs over a four month time span (). Studies suggest contraceptive education videos on tablets and iOS apps do not appear to affect LARC use, even with free contraceptives (); although counseling videos may increase patient preference for the use of IUDs while decreasing preference for condoms ().

Lack of knowledge and cost for patients, providers, and the health care system can be barriers to individuals’ LARC use (). Lack of training among providers and the upfront costs of LARC devices for clinics may be particular challenges in federally qualified health centers (FQHCs) that are small, located in rural areas, or have limited family planning funding (). Adolescents in all types of communities face these and additional barriers, such as insurance coverage gaps and out-of-pocket expenses, parental consent requirements and confidentiality issues, provider discomfort and misconceptions about the clinical appropriateness of youth use, and adolescents’ own lack of information and misconceptions about LARCs (, , , ).

One study suggests LARC users may be less likely to use condoms than oral contraceptive users, suggesting a need to incorporate messages about condom use to prevent sexually transmitted infections (STIs) in counseling efforts (). LARC users in the Contraceptive CHOICE Project were at higher risk of acquiring an STI; LARC users had lower rates of condom use than others who chose other contraceptives, but condom use did not change before and after LARC insertion (McNicholas 2017).

LARCs are highly cost-effective (, ), and more cost-effective than other methods of contraception such as condoms and birth control pills ().

Impact on Disparities

Likely to decrease disparities

Implementation Examples

From 2008 to 2014, long-acting reversible contraception (LARC) use increased more than any other contraceptive method (). From 2008 to 2013, inpatient postpartum LARC insertion also increased ().

There are various efforts at local, state, and federal levels to increase access to LARCs. The Contraceptive Choice Center (formerly the CHOICE project) in St. Louis (CHOICE) is an example of a local initiative, and efforts in Colorado and Iowa reflect partnerships between state governments and private donors (CHOICE, CDPHE-Title X, ). Delaware has also recently launched a public/private partnership called Contraceptive Access Now (DE-CAN). The Veteran Health Administration’s homeless outreach programs provide LARC access to homeless women veterans ().

The federal Affordable Care Act (ACA) reduced or eliminated the cost of long-acting reversible contraceptives for many women (Birgisson 2015, , , , Bearak 2016). However, states can restrict access to LARCs through insurance regulations and Medicaid eligibility requirements (). Variability in state Medicaid payment policies do not always address all aspects of care, frequently failing to include counseling, follow-up care, and removal (); for example, not all states have published guidance for Medicaid reimbursement for postpartum LARC (ACOG-Postpartum LARC)

Implementation Resources

Russo 2013a - Russo JA, Miller E, Gold MA. Myths and misconceptions about long-acting reversible contraception (LARC). Journal of Adolescent Health. 2013;52(4 Suppl):S14-S21.

AFY-LARC - Young women and long-acting reversible contraception (LARC). Advocates for Youth (AFY).

ACOG-LARC 2017 - American College of Obstetricians and Gynecologists (ACOG). Long-acting reversible contraception: Implants and intrauterine devices. Practice Bulletin No. 186. Obstetrics and Gynecology. 2017;130:e251–269.

CDC-CAP - Centers for Disease Control and Prevention (CDC). Improving contraceptive access: The Contraceptive Action Plan (CAP). Atlanta: US Department of Health and Human Services; 2018.

rhap-LARC Training - reproductive health access project (rhap). Hands-on reproductive health training center.

Citations - Evidence

* Journal subscription may be required for access.

AAP-Contraception 2014* - American Academy of Pediatrics (AAP) Committee on Adolescence. Contraception for adolescents. Pediatrics. 2014;134(4):e1244-e1256.

Baldwin 2013* - Baldwin MK, Edelman AB. The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: A review. Journal of Adolescent Health. 2013;52(4 Suppl):S47-S53.

Batra 2015* - Batra P, Bird CE. Policy barriers to best practices: The impact of restrictive state regulations on access to long-acting reversible contraceptives. Women’s Health Issues. 2015;25(6):612-615.

Beeson 2014* - Beeson T, Wood S, Bruen B, et al. Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs). Contraception. 2014;89(2):91-96.

Biggs 2015* - Biggs MA, Rocca CH, Brindis CD, Hirsch H, Grossman D. Did increasing use of highly effective contraception contribute to declining abortions in Iowa? Contraception. 2015;91(2):167-173.

Birgisson 2015 - Birgisson NE, Zhao Q, Secura GM, Madden T, Peipert JF. Preventing unintended pregnancy: The Contraceptive CHOICE Project in review. Journal of Women’s Health. 2015;24(5):349-353.

Blumenthal 2011* - Blumenthal PD, Voedisch A, Gemzell-Danielsson K. Strategies to prevent unintended pregnancy: Increasing use of long-acting reversible contraception. Human Reproduction Update. 2011;17(1):121-137.

Broecker 2016* - Broecker J, Jurich J, Fuchs R. The relationship between long-acting reversible contraception and insurance coverage: A retrospective analysis. Contraception. 2016;93(3):266-272.

Cochrane-Lopez 2016* - Lopez LM, Grey TW, Chen M, Tolley EE, Stockton LL. Theory-based interventions for contraception (Review). Lopez LM, ed. Cochrane Database of Systematic Reviews. 2016;(11):CD007249.

Eisenberg 2013* - Eisenberg D, McNicholas C, Peipert JF. Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents. Journal of Adolescent Health. 2013;52(4 Suppl):S59-S63.

Goldthwaite 2015* - Goldthwaite LM, Duca L, Johnson RK, Ostendorf D, Sheeder J. Adverse birth outcomes in Colorado: Assessing the impact of a statewide initiative to prevent unintended pregnancy. American Journal of Public Health. 2015;105(9):e60-e66.

Harper 2015* - Harper CC, Rocca CH, Thompson KM, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: A cluster randomised trial. The Lancet. 2015;386(9993):562-568.

Kofinas 2014* - Kofinas JD, Varrey A, Sapra KJ, et al. Adjunctive social media for more effective contraceptive counseling. Obstetrics & Gynecology. 2014;123(4):763-770.

Kumar 2016a* - Kumar N, Brown JD. Access barriers to long-acting reversible contraceptives for adolescents. Journal of Adolescent Health. 2016;59(3):248-253.

Lotke 2015* - Lotke PS. Increasing use of long-acting reversible contraception to decrease unplanned pregnancy. Obstetrics and Gynecology Clinics of North America. 2015;42(4):557-567.

Peipert 2012 - Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstetrics & Gynecology. 2012;120(6):1291-1297.

Ricketts 2014* - Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspectives on Sexual and Reproductive Health. 2014;46(3):125-132.

Rocca 2016* - Rocca CH, Thompson KMJ, Goodman S, Westhoff CL, Harper CC. Funding policies and postabortion long-acting reversible contraception: Results from a cluster randomized trial. American Journal of Obstetrics and Gynecology. 2016;214(6):716.e1-716.e8.

Secura 2014* - Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. The New England Journal of Medicine. 2014;371(14):1316-1323.

Steiner 2016* - Steiner RJ, Liddon N, Swartzendruber AL, Rasberry CN, Sales JM. Long-acting reversible contraception and condom use among female US high school students: Implications for sexually transmitted infection prevention. JAMA Pediatrics. 2016;170(5):428-434.

ACOG-642 2015 - American College of Obstetricians and Gynecologists (ACOG). Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Committee Opinion No. 642. Obstetrics and Gynecology. 2015;126:e44-48.

ACOG-LARC 2017 - American College of Obstetricians and Gynecologists (ACOG). Long-acting reversible contraception: Implants and intrauterine devices. Practice Bulletin No. 186. Obstetrics and Gynecology. 2017;130:e251–269.

Byker 2019* - Byker T, Myers C, Graff M. Can a social media campaign increase the use of long-acting reversible contraception? Evidence from a cluster randomized control trial using Facebook. Contraception. 2019;100(2):116–122.

Dineley 2018* - Dineley B, Patel T, Black M, et al. Video media in clinic waiting areas increases interest in most effective contraceptive methods. Journal of Obstetrics and Gynaecology Canada. 2018;40(10):1302–1308.

Francis 2017* - Francis JKR, Gold MA. Long-acting reversible contraception for adolescents: A review. Journal of the American Medical Association (JAMA) Pediatrics. 2017;171(7):694–701.

Gomez 2015 - Gomez AM, Fuentes L, Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. Perspectives on Sexual and Reproductive Health. 2015;46(3):171–175.

Goyal 2017 - Goyal V, Canfield C, Aiken ARA, et al. Postabortion contraceptive use and continuation when long-acting reversible contraception is free. Obstetrics and Gynecology. 2017;129(4):655-662.

Higgins 2018 - Higgins TM, Dougherty AK, Badger GJ, et al. Comparing long-acting reversible contraception insertion rates in women with Medicaid vs. private insurance in a clinic with a two-visit protocol. Contraception. 2018;97(1):76–78.

Lindo 2017 - Lindo JM, Packham A. How much can expanding access to long-acting reversible contraceptives reduce teen birth rates? American Economic Journal: Economic Policy. 2017;9(3):348–376.

McNicholas 2017 - McNicholas CP, Klugman JB, Zhao Q, et al. Condom use and incident sexually transmitted infection after initiation of long-acting reversible contraception. American Journal of Obstetrics and Gynecology. 2017;217(6):672.e1-672.e6.

NBER-Kelly 2019* - Kelly AM, Lindo JM, Packham A. The power of the IUD: Effects of expanding access to contraception through Title X clinics. National Bureau of Economic Research (NBER). 2019: Working Paper 25656.

NWHN 2017 - National Women’s Health Network (NWHN). Long-acting reversible contraception statement of principles. 2017.

Potter 2018 - Potter JE, Coleman-Minahan K, White K, et al. Contraception after delivery among publicly insured women in Texas: Use compared with preference. Obstetrics and Gynecology. 2018;130(2):393–402.

Snyder 2018a* - Snyder AH, Weisman CS, Liu G, et al. The impact of the affordable care act on contraceptive use and costs among privately insured women. Women’s Health Issues. 2018;28(3):219–223.

Stevens 2017* - Stevens J, Lutz R, Osuagwu N, et al. A randomized trial of motivational interviewing and facilitated contraceptive access to prevent rapid repeat pregnancy among adolescent mothers. American Journal of Obstetrics and Gynecology. 2017;217(4):423.e1-423.e9.

Strasser 2017* - Strasser J, Borkowski L, Couillard M, et al. Access to removal of long-acting reversible contraceptive methods is an essential component of high-quality contraceptive care. Women’s Health Issues. 2017;27(3):253–255.

Tomlin 2017* - Tomlin K, Bambulas T, Sutton M, et al. Motivational interviewing to promote long-acting reversible contraception in postpartum teenagers. Journal of Pediatric and Adolescent Gynecology. 2017;30(3):383–388.

Citations - Implementation Examples

* Journal subscription may be required for access.

Batra 2015* - Batra P, Bird CE. Policy barriers to best practices: The impact of restrictive state regulations on access to long-acting reversible contraceptives. Women’s Health Issues. 2015;25(6):612-615.

Bearak 2016 - Bearak JM, Finer LB, Jerman J, Kavanaugh ML. Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: An analysis of insurance benefit inquiries. Contraception. 2016;93(2):139-144.

Biggs 2015* - Biggs MA, Rocca CH, Brindis CD, Hirsch H, Grossman D. Did increasing use of highly effective contraception contribute to declining abortions in Iowa? Contraception. 2015;91(2):167-173.

Birgisson 2015 - Birgisson NE, Zhao Q, Secura GM, Madden T, Peipert JF. Preventing unintended pregnancy: The Contraceptive CHOICE Project in review. Journal of Women’s Health. 2015;24(5):349-353.

Pace 2016* - Pace LE, Dusetzina SB, Keating NL. Early impact of the Affordable Care Act on uptake of long-acting reversible contraceptive methods. Medical Care. 2016;54(9):811-817.

Ricketts 2014* - Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspectives on Sexual and Reproductive Health. 2014;46(3):125-132.

CHOICE - The Contraceptive Choice Project. Washington University School of Medicine in St. Louis.

CDPHE-Title X - Colorado Department of Public Health & Environment (CDPHE). About Colorado Title X family planning.

DE-CAN - Delaware Division of Public Health and Upstream USA. Delaware CAN.

ACOG-Postpartum LARC - American College of Obstetricians and Gynecologists (ACOG). Medicaid reimbursement for postpartum LARC by state. Women's Health Care Physicians. 2019.

Gawron 2017* - Gawron L, Redd A, Suo Y, et al. Long-acting reversible contraception among homeless women veterans with chronic health conditions: A retrospective cohort study. Medical Care. 2017;55:S111-120.

Kavanaugh 2018* - Kavanaugh ML, Jerman J. Contraceptive method use in the United States: Trends and characteristics between 2008, 2012 and 2014. Contraception. 2018;97(1):14–21.

Moniz 2017* - Moniz MH, Chang T, Heisler M, et al. Inpatient postpartum long-acting reversible contraception and sterilization in the United States, 2008-2013. Obstetrics and Gynecology. 2017;129(6):1078–1085.

Vela 2018* - Vela VX, Patton EW, Sanghavi D, et al. Rethinking Medicaid coverage and payment policy to promote high value care: The case of long-acting reversible contraception. Women’s Health Issues. 2018;28(2):137–143.

Date Last Updated

Aug 13, 2019