As Unplanned Pregnancy Rates Drop, Births Improve  

Healthy young woman
"We want women to feel empowered in their choices and empowered in their pregnancies," says NICHQ Senior Project Director, Zhandra Levesque, MPH.

Unplanned pregnancies often result in delayed prenatal care, which can increase health risks for both mother and baby. They’re also associated with higher numbers of premature births and lower birth weights, which affect children’s health outcomes. Simply put, fewer unplanned pregnancies means more healthy moms and babies. It’s a fact that has ignited efforts to address unplanned pregnancies as a strategy to improve infant mortality rates.

With the rate of unplanned pregnancies dropping by six percent in recent years, these efforts are proving successful and can be used to motivate future improvement efforts. Nearly half of U.S. pregnancies are still unplanned and accompanied by significant disparities. Seventy-five percent of teenage pregnancies are unintended and black and Hispanic women have far higher rates of unintended pregnancies than white mothers. Much of these disparities are a result of less education, lower income and other social determinants of health that can further exasperate a pregnancy’s risk.

“We can change these numbers,” says Zhandra Levesque, MPH, project director for the NICHQ-led Collaborative Improvement and Innovation Network to Reduce Infant Mortality (Infant Mortality CoIIN). “We need to keep investing in strategies that empower women to protect and take pride in their sexual and reproductive health.”

Long-acting reversible contraceptives (LARCs) are one of those strategies. LARCS, which include IUDs and birth control implants, are more effective than any other form of birth control, in large part because they require minimum maintenance, which leaves little room for user error. Yet, despite their effectiveness, they’re only used by 10 percent of women.

“If we’re thinking about strategies to spread and scale, there’s a clear opportunity here,” says Levesque. “Especially when we consider the bright spots we uncovered during the Infant Mortality CoIIN; each success provides a foundation for states across the country to build on.”

Incorporate LARCs into Postpartum Care

During the postpartum care that immediately follows delivery, providers are already engaging mothers in conversations about healthy birth spacing. These conversations offer a seamless opportunity to discuss the effectiveness of LARCs as a contraception choice and, if the mother chooses, perform immediate insertion.

They’re also an opportunity to reach mothers who might not be able to return for their follow-up appointments, which may account for more than half of mothers on Medicaid. Finding transportation, getting time off from jobs, accessing affordable childcare—each can make it more difficult for a new mother to get back to a clinical setting. Helping all mothers return for follow-up care should always be the highest priority; but providing these services immediately guarantees all mothers immediate options.

“Postpartum insertion is a strategy that can promote healthy birth spacing, and in return improved birth outcomes for women and infants,” affirms Levesque. “This means it deserves our attention. We want to give mothers every chance to make informed decisions about their future pregnancy habits, especially since they’re already under the many stresses imposed by the social determinants of health that regularly affect their lives.”

LARCs have steep upfront costs though, which can overshadow their long term economic benefit. Because of this, hospitals are less likely to stock them and have them on hand for postpartum insertion. As a result, many mothers are still forced to wait until their follow-up visit. Recognizing the inherent risks in this approach, South Carolina implemented a policy through Medicaid that offered hospitals full reimbursement if they inserted LARCs postpartum and prior to discharge.

For policy improvements to be successful they don’t just need to be feasible; they also need buy-in from stakeholders across the hospital. Clinicians need to know how to insert the devices and all caregivers should be educated on LARCs’ effectiveness and ease of use. Knowing this, South Carolina’s team worked to identify champions at every stage of the mother’s journey. From prenatal care providers, to physicians and nurses, to lactation consultants, each are potential resources for pregnant mothers and each received appropriate training. Thanks to these efforts, more new mothers better understand their reproductive choices and have the freedom to take immediate advantage of LARCs.

Interested in finding out how to implement this policy in your state? Use South Carolina’s toolkit. Or, check out our full Infant Mortality CoIIN Prevention Toolkit for full case studies, videos and other resources. 

Leverage Women as Stakeholders

LARCs come with many misconceptions: they’re only available for women who have had children, they have unmanageable side effects, they cause abortions. These misconceptions, among others, mean that too many women are making reproductive choices based on faulty information.

Understanding the social, cultural and historic perspective on LARCs can help states address those misconceptions. North Carolina used surveys to reach out to women directly, asking them what they knew, heard and believed about LARCs. By working with community based programs, like Healthy Start, and making the survey available in both English and Spanish, they identified 100 diverse participants from different communities across the state.

The results were illuminating. Some women revealed that their providers did not offer LARCs as an option; and many women based their contraceptive choices on the advice and experiences of their friends.

These responses sparked North Carolina to change how they approached contraception education. They developed a pilot to test a series of life-planning questions that providers could use to improve conversations with patients. They also recruited young adults to join a community leadership council so that local voices are represented in future improvement efforts and spread through their communities. Each of these strategies helps elevate women as active stakeholders in decisions that directly affect their reproductive health.

“Reproductive choices are personal,” says Levesque. “That’s why each of these strategies, whether pre- or postpartum, involves building women’s self-efficacy. We want women to feel empowered in their choices and empowered in their pregnancies. Improving LARC education and access, ensuring it’s an option available to all women—it’s a step towards giving women the choices they deserve and ultimately improving children’s health.”

Ready to uncover more strategies to increase access to LARCs? Check out this issue brief, which provides a deeper dive into LARCs' current availability, barriers to prescribing it and potential Medicaid reimbursement models.Or learn more about a learning community developed by ASTHOS, dedicated to increasing immediate postpartum insertion.