Did increasing use of highly effective contraception contribute to declining abortions in Iowa?

doi:10.1016/j.contraception.2014.10.009

Contraception

Volume 91, Issue 2, February 2015, Pages 167-173

https://doi.org/10.1016/j.contraception.2014.10.009 Get rights and content

Abstract

Background

Between 2006 and 2008, Iowa increased access to family planning services through a Medicaid expansion and a privately funded initiative. During this same time, Iowa expanded access to abortion through telemedicine provision of medical abortion. Despite increased access to abortion services, abortions in Iowa have declined. This study assessed whether increased provision of long-acting reversible contraception (LARC) may have contributed to the abortion decline.

Study design

We analyzed abortion data from Iowa vital statistics and LARC use data from 14 family planning agencies’ records (N= 544,248) for the years 2005 to 2012. Mixed-effects logistic regression analyses assessed whether changes in the percentage of LARC users were associated with subsequent reductions in abortion across the state.

Results

From 2005 to 2012, the number of family planning clients using LARC increased from 539 to 8603 (less than 1% to 15%); the number of resident abortions decreased from 5198 to 3887 (8.7 per 1000 women aged 15–44 to 6.7). There were reduced odds of abortion (adjusted odds ratio, 0.96; 95% confidence interval: 0.94–0.97) with increased LARC use.

Conclusions

Declines in abortion followed increases in LARC use in Iowa.

Introduction

The United States has observed a steady decline in abortions since the early 1990s, reaching 16.9 abortions per 1000 women aged 15–44 years in 2011, the lowest level since the procedure became legal in 1973 [1], [2], [3]. A number of factors may explain this decrease, including changes in demographics, desired family size, access to contraceptive and abortion services, and economic conditions.

Some researchers have suggested that the abortion decline may be due to use of more efficacious methods such as long-acting reversible contraception (LARC) [1], [3]. LARC methods include the intrauterine contraceptive device (IUD) and the single-rod contraceptive implant [4]. There has been widespread interest in LARC methods because of their safety and suitability for nearly all women, including adolescents, and their potential to reduce unintended pregnancies [5], [6], [7], [8].

Emerging evidence suggests that LARC use may be associated with reductions in unintended pregnancies and abortions. The Contraceptive CHOICE project, a prospective cohort study conducted in the St. Louis area, provided contraception at no cost to nearly 10,000 women, with a particular emphasis on promoting LARC use [9], [10]. Results from this study showed that the rates of abortion in St. Louis were markedly lower than in comparable regions following the introduction of no-cost LARC [9]. However, because this study was an observational study limited to a small geographic area, it is unknown whether results are generalizable to other settings. More recently, a study in Colorado found that a statewide intervention to increase LARC access among low-income women corresponded to a decline in abortions [11]. Research isolating the effects of LARC use on abortion is limited.

Declines in access to abortion services, due to either legal restrictions or declines in the number of facilities, could also play a role in decreasing the number of abortions in the United States. However, most legislative restrictions were implemented long after the abortion rate began to decline in the early 1990s, and thus, any real impact of these policy changes is yet to be seen [12], [13]. As researchers study the effects of recent legislative restrictions on women’s access to abortion services, it will be important to understand the independent contributions of other factors, such as changes in the use of effective contraceptive methods that may also impact the abortion rate.

In this study, we investigated whether changes in LARC use over time were followed by reductions in abortions between 2005 and 2012 in one Midwestern state, Iowa. Like other states in the Midwest, Iowa has a relatively low and declining abortion rate [3]. This trend coincides with a decline in all live births, including teen births [14]. We use family planning visit and vital statistics data to examine whether baseline changes in LARC use led to subsequent reductions in the number of abortions within each of Iowa’s 26 Induced Termination of Pregnancy (ITOP) regions. This longitudinal analysis offers a new contribution to the literature by considering the temporality of LARC use and abortion, a prerequisite to establishing causation. To do so, we assess changes within Iowa’s 26 ITOP regions over time while controlling for baseline and other known confounders in a real-world setting. We hypothesized that larger regional increases in LARC use would be associated with fewer abortions.

Section snippets

Study setting and context

From 2005 to 2012, Iowa presents a unique setting and time period to test the association between LARC use and abortion. In contrast to many other US states that restricted access to abortion during our study period, access to abortion care expanded in Iowa [3]. Since 2008, women in Iowa can obtain medical abortion through telemedicine provision. By 2010, this service was available in 15 facilities throughout the state. All facilities offering surgical abortions prior to the introduction of

Results

Statewide LARC use at these family planning agencies increased from less than 1% of reproductive age family planning clients in 2005 to 15% in 2012, with similar proportions using the IUD and implant in 2012 (Table 1). In absolute numbers, this represents an increase of 8064 LARC users during our study period. The percentage of LARC users among reproductive age women in the population increased from 0.09% in 2005 to 1.48% in 2012. The number of in-state resident abortions per 1000 reproductive

Discussion

This study demonstrates a significant longitudinal association between increases in LARC use and the subsequent declines in abortion across Iowa regions. Our estimates suggest that a small increase of 1 new LARC user per 100 women in a region was associated with a 4% decline in abortions each year. This decline happened in conjunction with an increase in the number of facilities offering abortion care to women, particularly in rural and remote areas [15]. Given the increase in abortion access

Acknowledgments

The authors thank Susan Philliber, the study's co-principal investigator; Abigail Arons, Rita Turner, Ashley Philliber and Louis Mortillaro for project support; John Kornak and Charles McCulloch for statistical support; and all of the participating Iowa-Initiative-funded agencies and staff.

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Using data on all visits to Colorado Title X clinics between 2007 and 2016 for women aged 10–49 years, we described trends in contraceptive method use by age group and race/ethnicity prior to and following the implementation of CFPI.
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The program also provided funding to Title X clinics to increase the availability of LARCs through training to staff and providers about LARC insertion, promotion, and counseling, as well as technical assistance for billing, coding, and clinic management. A similar program, the Iowa Initiative to Reduce Unintended Pregnancies, implemented from 2007 to 2013, was also primarily a supply-side intervention that aimed to remove cost barriers to LARCs and increase funding and capacity at Title X clinics (Biggs et al., 2015). The St. Louis–based Contraceptive CHOICE project, which took place from 2007 to 2011, offered free access to contraceptives, with an emphasis on LARCs, to both women who were not on birth control but expressed interest in doing so and women who expressed interest in switching methods.
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^☆: This study was supported by an anonymous foundation.

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Original research articleDid increasing use of highly effective contraception contribute to declining abortions in Iowa?☆

Abstract

Background

Study design

Results

Conclusions

Introduction

Section snippets

Study setting and context

Results

Discussion

Acknowledgments

Contraception

Contraception

Contraception

Contraception

Contraception

Fertil Steril

J Pediatr Adolesc Gynecol

Womens Health Issues

Womens Health Issues

Abortion surveillance — United States, 2010

Morb Mortal Wkly Rep Surveill Summ

Abortion surveillance — United States, 2005

MMWR Surveill Summ

Abortion incidence and service availability in the United States, 2011

Perspect Sex Reprod Health

Contraceptive efficacy

Long-acting reversible contraception: a practical solution to reduce unintended pregnancy

Minerva Ginecol

Preventing unintended pregnancies by providing no-cost contraception

Obstet Gynecol

Effectiveness of long-acting reversible contraception

N Engl J Med

Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women

Perspect Sex Reprod Health

Original research article
Did increasing use of highly effective contraception contribute to declining abortions in Iowa?☆