Ob-Gyns Issue Recommendations to Improve Access to Contraception for More Women

New Guidelines Detail Importance of Removing Barriers to Access

Washington, DC—Contraception is an essential part of preventive care and all women should have unhindered and affordable access to all contraceptives approved by the U.S. Food and Drug Administration (FDA), a new Committee Opinion from the American College of Obstetricians and Gynecologists concludes.

The guidelines, “Access to Contraception,” come at the end of a year in which, despite overwhelming evidence of the value of contraceptives to American women, families, and the healthcare system overall, family planning was a major topic in the courts, legislative bodies, and electoral campaigns.

“Contraception improves the health of women, children and families as well as communities overall; reduces maternal mortality; and enhances economic stability for women and their families. The value of contraception has been proven time and again,” said Wanda Kay Nicholson, MD, Chair of the College’s Committee on Health Care for Underserved Women, which compiled the recommendations. “But with 49 percent of pregnancies unintended, it is clear that we need to work hard to improve access to birth control, including more-effective contraceptive methods like long-acting reversible contraceptives.”

The Committee Opinion includes 18 recommendations for policies and practices that will increase availability of the full range of contraceptive methods and that will remove existing and potential barriers. The recommendations run the gamut from patient education to coverage policy to removing existing restrictions.

These recommendations include:

• Full implementation of the Affordable Care Act (ACA) requirement that new and revised private health insurance plans cover all FDA-approved contraceptives without cost sharing, including non-equivalent options from within one method category (e.g., both levonorgestrel and copper intrauterine devices);
• Easily accessible alternative contraceptive coverage for women who receive health insurance through employers and plans exempted from the contraceptive coverage requirement;
• Medicaid expansion in all states, an action critical to the ability of low-income women to obtain improved access to contraceptives;
• The right of women to receive prescribed contraceptives or an immediate informed referral from all pharmacies;
• Inclusion of all contraceptive methods, including LARC, on all payer and hospital formularies;
• Over-the-counter access to oral contraceptives with accompanying full insurance coverage or cost supports; and
• Payment and practice policies that support provision of 3-13 month supplies of combined hormonal methods to improve contraceptive continuation.

“We can prevent unintended pregnancy and help ensure that women have the contraceptive care necessary to have healthy families if and when they want to,” said Dr. Nicholson. “But we must remove barriers and promote access for all American women, and we must support policies that will increase and improve utilization of contraceptives.”

Committee Opinion #616, “Access to Contraception,” will be published in the January issue of Obstetrics & Gynecology.

Other recommendations published in the January 2015 issue of Obstetrics & Gynecology:

Committee Opinion #616 “Newborn Screening and the Role of the Obstetrician–Gynecologist” (Revised)

ABSTRACT: Newborn screening is a mandatory state-based public health program that provides all newborns in the United States with presymptomatic testing and necessary follow-up health care for a variety of medical conditions. The goal of this essential public health program is to decrease morbidity and mortality by screening for disorders in which early intervention will improve neonatal and long-term health outcomes. The results of surveys and focus groups of expectant parents demonstrate that women and their families would like to receive information about newborn screening during their prenatal care visits. Providing newborn screening information during prenatal care visits can be accomplished in a number of ways and should be adapted to individual practice style.

Committee Opinion #617 “End-of-Life Decision Making” (Revised)

ABSTRACT: Obstetrician–gynecologists care for women throughout their lifespans and are in an ideal position to have ongoing discussions with healthy patients about their values and wishes regarding future care and to encourage them to complete an advance directive for health care. In addition, situations may arise in which obstetrician–gynecologists need to participate in end-of-life care. When end-of-life decisions need to be made while a woman is pregnant, the level of ethical complexity often is increased. The purpose of this Committee Opinion is to discuss ethical issues related to end-of-life care, historical and legal constructs, patient–physician communication, intradisciplinary and interdisciplinary collaboration, and educational opportunities pertinent to obstetrician–gynecologists and other providers of women's health care.

Committee Opinion #618 “Ovarian Reserve Testing” (NEW!)

ABSTRACT: The main goal of ovarian reserve testing is to identify those individuals who are at risk of decreased or diminished ovarian reserve, commonly known as DOR. Although ovarian reserve testing cannot predict the end of one's reproductive years, results outside the range expected for a patient's age can encourage the individual to pursue more aggressive treatment options to achieve pregnancy. Ovarian reserve testing should be performed for women older than 35 years who have not conceived after 6 months of attempting pregnancy and women at higher risk of diminished ovarian reserve. When test results suggest decreased or diminished ovarian reserve, if appropriate, an infertility evaluation should be initiated. It is reasonable to counsel the woman that her window of opportunity to conceive may be shorter than anticipated, and attempting to conceive sooner rather than later is encouraged. Compared with women of similar age, women with diminished ovarian reserve commonly have regular menses but a reduced quantity of ovarian follicles and, thus, may have a limited response to ovarian stimulation with fertility medications and reduced fecundity (probability of achieving a live birth in a single reproductive cycle). At this time, ovarian reserve testing results cannot be extrapolated to predict the likelihood of spontaneous conception.

Committee Opinion #619 “Gynecologic Surgery in the Obese Woman” (NEW!)

ABSTRACT: Obesity is a serious problem worldwide and particularly in the United States, and in women is associated with an increased risk of death and morbid conditions (including hypertension, diabetes mellitus, obstructive sleep apnea, and hypercholesterolemia) as well as malignancies such as endometrial and postmenopausal breast cancer. Adverse effects after gynecologic surgery, such as surgical site infection, venous thromboembolism, and wound complications, are more prevalent in obese women than in normal-weight women. Preoperative consultation with an anesthesiologist should be considered for the obese patient in whom the possibility of obstructive sleep apnea is suspected on clinical grounds or who is at risk of coronary artery disease, has a difficult airway, or has poorly controlled hypertension. Gynecologic surgeons should have the knowledge to counsel obese women on the risks specific to this group. As with all patients, evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy. Postoperative care of the obese patient is similar to postoperative care of the normal-weight patient and comorbid conditions should be taken into consideration.

Committee Opinion #620 “Salpingectomy for Ovarian Cancer Prevention” (NEW!)

ABSTRACT: Ovarian cancer has the highest mortality rate out of all types of gynecologic cancer and is the fifth leading cause of cancer deaths among women. Current attempts at screening for ovarian cancer have been unsuccessful and are associated with false-positive test results that lead to unnecessary surgery and surgical complications. Prophylactic salpingectomy may offer clinicians the opportunity to prevent ovarian cancer in their patients. Randomized controlled trials are needed to support the validity of this approach to reduce the incidence of ovarian cancer. The approach to hysterectomy or sterilization should not be influenced by the theoretical benefit of salpingectomy. Surgeons should continue to observe and practice minimally invasive techniques.

Committee Opinion #621 “Patient Safety and Health Information Technology” (NEW!)

ABSTRACT: The advantages of health information technology (IT) include facilitating communication between health care providers; improving medication safety, tracking, and reporting; and promoting quality of care through optimized access to and adherence to guidelines. Health IT systems permit the collection of data for use for quality management, outcome reporting, and public health disease surveillance and reporting. However, improvement is needed with all health IT, especially regarding design, implementation, and integration between platforms within the work environment. Robust interoperability is critical for safe care, but this goal has proved elusive. Significant patient safety concerns already have been recognized; it is important to keep patient safety and quality as the primary focus.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org