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 (Parks 2016*). 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 (Batra 2015*).

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 (NBER-Kelly 2019*, Goyal 2017, Lindo 2017, Harper 2015*, Biggs 2015*, Ricketts 2014*). LARCs are recommended as a safe and effective first-line choice of birth control for teens (ACOG-LARC 2017, AAP-Contraception 2014*) 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 (NBER-Kelly 2019*, Birgisson 2015, Ricketts 2014*, Goldthwaite 2015*) and reduce unintended pregnancy among teens (NBER-Kelly 2019*, Lindo 2017, Ricketts 2014*, Secura 2014*, Peipert 2012) and adults (NBER-Kelly 2019*, Ricketts 2014*). 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 (Snyder 2018a*, Broecker 2016*, Rocca 2016*) 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 (Biggs 2015*).

Training providers to deliver broad-based counseling about birth control options and insert IUDs may increase counseling and LARC selection for all patients (Rocca 2016*, Harper 2015*), but may only increase LARC initiation and reduce pregnancy rates among patients who receive counseling at family planning visits (Harper 2015*). For patients whose visits are not likely to be covered by insurance, studies suggest counseling alone increases LARC selection but not initiation (Harper 2015*, Rocca 2016*); initiation appears to be associated with sufficient insurance coverage (Rocca 2016*). 

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 (Strasser 2017*, 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 (Stevens 2017*). 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 (Tomlin 2017*).

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 (Kofinas 2014*), though a campaign using only Facebook advertisements did not detect a change in the use of LARCs over a four month time span (Byker 2019*). Studies suggest contraceptive education videos on tablets and iOS apps do not appear to affect LARC use, even with free contraceptives (Cochrane-Lopez 2016*); although counseling videos may increase patient preference for the use of IUDs while decreasing preference for condoms (Dineley 2018*).

Lack of knowledge and cost for patients, providers, and the health care system can be barriers to individuals’ LARC use (Lotke 2015*). 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 (Beeson 2014*). 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 (Francis 2017*, Kumar 2016a*, Eisenberg 2013*, Baldwin 2013*).

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 (Steiner 2016*). 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 (Batra 2015*, Eisenberg 2013*), and more cost-effective than other methods of contraception such as condoms and birth control pills (Blumenthal 2011*).

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 (Kavanaugh 2018*). From 2008 to 2013, inpatient postpartum LARC insertion also increased (Moniz 2017*).

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, Biggs 2015*). 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 (Gawron 2017*).

The federal Affordable Care Act (ACA) reduced or eliminated the cost of long-acting reversible contraceptives for many women (Birgisson 2015, Ricketts 2014*, Biggs 2015*, Pace 2016*, Bearak 2016). However, states can restrict access to LARCs through insurance regulations and Medicaid eligibility requirements (Batra 2015*). Variability in state Medicaid payment policies do not always address all aspects of care, frequently failing to include counseling, follow-up care, and removal (Vela 2018*); for example, not all states have published guidance for Medicaid reimbursement for postpartum LARC (ACOG-Postpartum LARC)

Implementation Resources

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.

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

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.

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.

Citations - Evidence

* Journal subscription may be required for access.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

Citations - Implementation Examples

* Journal subscription may be required for access.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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

Date Last Updated