The relationship between contraceptive insurance coverage and subsequent abortion
Abortion, Contraception
Awarded 2017
Complex Family Planning Fellowship Research
Antoinette Nguyen, MD, MPH
The University of North Carolina at Chapel Hill

Immediate post-abortion contraception is safe, acceptable to patients, and effective at reducing unintended pregnancy and subsequent abortion. However, many people face financial barriers that limit their ability to obtain effective contraception at the same clinic visit as an abortion. Out-of-pocket costs for abortion care and contraception can be substantial for many people, especially among those without insurance coverage. These financial barriers are particularly critical in North Carolina where Medicaid, state employee health plans, and private insurance plans offered through the Affordable Care Act marketplace restrict abortion coverage. Additionally, the state-sponsored reproductive health program for North Carolina residents whose income is at or below 195% of the federal poverty level does not allow for same-day enrollment and approval. Finally, as of May 2020, North Carolina has continued to decline federally subsidized Medicaid expansion, further limiting the number of people with insurance coverage for contraception.
The aim of our study was to investigate if there was an association between contraception insurance coverage at the time of abortion and subsequent pregnancy and abortion within 12 months. We conducted a cohort study of people who previously underwent an induced abortion in 2015-2016 at a free-standing health center in North Carolina and did not desire pregnancy within 12 months. Participants completed phone or email surveys.
We found that participants who had contraceptive insurance coverage at the time of abortion had a 75% reduced risk of being pregnant in the subsequent year. They were also almost four times more likely to have received immediate post-abortion LARC or DMPA after their index abortion but had similar LARC or DMPA use 12 months later compared to those without insurance coverage.
Our study highlights the higher risk of pregnancy after an induced abortion among people without insurance coverage for contraception compared to those with coverage. Health policy and legislation must be grounded in science and evidence with the aim to expand access to the full range of contraception for people who desire contraception at the time of their abortion.