Out of pocket, out of mind: What will women pay for post-abortion contraception?
Awarded 2015
Complex Family Planning Fellowship Research
Jamie Krashin, MD
The University of North Carolina at Chapel Hill

Background:  Although post-abortion contraception is known to be acceptable, safe, and effective, many women leave abortion clinics without contraception and are therefore at risk for repeat unintended pregnancy.1-11    Abortion clinic staff and providers often cite cost as a barrier to women receiving immediate post-abortion contraception.12,13  Insurance copayments and out-of-pocket costs have been shown to affect uptake of long-acting reversible contraception in non-abortion settings among privately insured women.14-19  However, little data exists about these 2 cost variables in an abortion clinic and among a women with a mix of private, public, and no insurance.
Statement of purpose: We sought to understand how cost may be related to contraceptive uptake in an abortion clinic.
Methodology:  We collected data from women at an abortion clinic in Chapel Hill, North Carolina, starting after they were counseled and consented to their abortion until after their abortion.  The data was collected from in-person questionnaires and the women’s clinic records.  Women who participated in the study were at least 18 years old, fluent in English or Spanish, and had come to clinic for an abortion. 
We compared two groups of women: those whose clinic chart showed that they had insurance coverage for contraception and those whose clinic chart did not show they had such insurance coverage.  We looked for a difference in the proportion of women in each group who left clinic with contraception.  For our study, leaving with contraception meant going home with intrauterine contraception, an implant, or a shot.  We chose these methods because women could use insurance to pay for them at the clinic.  We studied enough women to see a 15% difference in the proportion of women who left clinic with contraception between the groups, if such a difference existed.  For each of these possible relationships, we looked to see if other factors—such as gestational age, race, educational level—affected how strong the original relationship is.
Important findings: Women with insurance coverage for contraception were more than 5 times as likely to leave clinic with immediate post-abortion contraception than women without insurance coverage for contraception.  However, only 14% of women received immediate post-abortion contraception.  Almost ¾ of women without insurance who did receive immediate post-abortion contraception had qualified for and received a free intrauterine device or implant through the Ryan LARC Program.
Summary statement:  Increased access to insurance coverage for contraception at the time of abortion may increase uptake of effective contraception.  Opportunities to increase women’s access to insurance in this setting at the patient, clinic, and policy level should be further explored.