Contraception workforce varies widely across US
There is significant variation in the distribution and types of providers who prescribe birth control in the United States, as well as among those who participate in Medicaid, according to an observational study.
These variations have left large gaps in the provision of highly effective services, so increasing the numbers and types of providers who offer family planning will be necessary to establish comprehensive reproductive health care, the researchers wrote in the American Journal of Obstetrics and Gynecology.
“We know that the health care workforce can enable or limit access to essential health care services, including contraception. But little is known about the contraception workforce at the national level,” author Julia Strasser, DrPH, MPH, senior research scientist at the George Washington University Milken Institute School of Public Health, told Healio.
“We conducted this study to understand more about the supply, distribution, types of services offered and Medicaid acceptance of this important workforce,” Strasser continued.
The researchers constructed a database of the nation’s contraceptive workforce, focused on who prescribes and provides IUDs, implants, depot medroxyprogesterone acetate (DPMA), oral contraception, hormonal patches and vaginal rings.
They used multiple datasets, including the proprietary health information company IQVIA’s prescription claims, pre-adjudicated medical claims and the OneKey health care provider dataset; the National Plan and Provider Enumeration System dataset; and Census Bureau American Community Survey data on population demographics.
The 289,926 prescription contraception providers that the researchers identified included OB/GYNs, nurse midwives, family medicine providers, internal medicine providers, pediatric providers, advanced practice nurses and physician assistants.
“Previous research on the workforce providing contraception has largely relied on surveys, which have limited sample sizes or focus on only a subset of providers or both,” said Strasser. “Our study fills a gap in the previous literature by using multiple, national-level datasets to describe who is providing contraception, what they are providing and where they are providing it.”
According to the analysis, 73.1% of OB/GYNs, 72.6% of nurse midwives, 51.4% of family medicine physicians, 32.4% of pediatricians, 25.2% of advanced practice nurses, 19.8% of internal medicine physicians and 19.4% of physician assistants prescribed the pill, patch and/or ring.
OB/GYNs and nurse midwives were more likely to prescribe the pill, patch or ring, and they were most likely to prescribe and provide contraception overall. But the greatest numbers of contraception providers were family medicine physicians (n = 72,725) and advanced practice nurses (n = 70,115).
In fact, family medicine, internal medicine, pediatricians, advanced practice nurses and physician assistants make up 75.9% (n = 219,911) of the total contraception provider workforce.
Further, 73% of OB/GYNs prescribed the pill, 30% prescribed the patch and 49% prescribed the ring. The researchers said they observed this general pattern across other professions and specialties, though at lower rates.
The ratio of all primary care providers who provide contraception varied state to state, ranging from 27.9 providers per 10,000 females between the ages of 15 and 44 in New Jersey to 74.2 providers per 10,000 females in Maine.
Also, 1,411 of the 3,006 counties in the U.S. had no OB/GYNs or nurse midwives who provide contraception, but 674 of these counties had family medicine providers, advanced practice nurses or physician assistant who did.
“This study shows that there is substantial state-to-state variation in the contraception workforce. While there are many determinants that can affect access to care, the provider workforce in particular is a critical one,” said Strasser.
Proportions of prescription contraception providers that accepted Medicaid (n = 263,350) varied by state as well, ranging from 55.5% in Texas to 89.1% in Vermont. The rate of providers accepting Medicaid also varied within states by specialty.
“The vast majority of OB/GYNs in every state accept Medicaid for prescription contraception, while much lower proportions of internal medicine physicians do so,” Strasser said. “This means that for Medicaid patients, access to care may depend heavily on both where they live and on which provider types are located in their area.”
The researchers also found that fewer providers offer the contraceptive shot, IUDs and implants than prescription contraception. Less than 20% of family medicine physicians and less than 4% of internal medicine physicians and pediatricians provide IUDs or implants.
Different populations may benefit from different types of providers as well, according to the researchers. Rural areas may take advantage of family medicine physicians and advanced practice nurses, while adolescent populations may be served more by pediatricians.
But the researchers said they were concerned by the low rates of family medicine, internal medicine and pediatric physicians that provide IUDs and implants, especially to patients who do not have other providers in their area or who may face “social determinant barriers to care.”
“Increasing provision of these services — through increased training, education and adequate reimbursement — would improve quality of care, especially in underserved populations,” Strasser said.
The researchers said that changes at multiple levels, including policy and practice, will be necessary to expand the contraception workforce. They called for further examinations of provider characteristics, programs and policies associated with contraception service provision, with longitudinal analysis of how programs and policies affect contraception outcomes.
“Our database on the prescription contraception workforce will soon become publicly available, upon request,” Strasser said, adding that it is expected to be available on Sept. 3.
“Researchers and other interested parties will be able to request access to county-level data for the entire U.S. on providers of the pill, patch and ring, as well as whether those providers accept Medicaid,” she said.
Perspective
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This is an observational study compiling data from several national databanks regarding contraceptive practices by medical specialty and location within the U.S. The authors used prescription claims and procedural codes and then cross referenced with national physician databases to locate the physician or advanced practice provider (APP) within the U.S. and identify the medical specialty. Previous studies evaluating the contraceptive practices of physicians and APPs were based on surveys, which were limited by number of respondents.
The results of the study suggest that OB/GYN doctors are the most likely to prescribe contraception (oral contraceptives, patch, ring) and provide long-acting contraception (IUD, implant, Depo-Provera shot). Family medicine doctors prescribe a large number of contraceptives, as the number of family medicine physicians practicing in the U.S. is greater than the number of OB/GYN doctors and midwives. Internal medicine doctors and pediatricians are the least likely to prescribe contraception.
The average age of the patient population seeing an internal medicine doctor on average is probably higher than the average age of the patients who see a family medicine doctor or an OB/GYN, which would help to explain the discrepancy in prescribing habits between internal medicine and family medicine.
The difference in prescribing habits of long-acting contraception between medical specialties (OB/GYN vs. family medicine vs. internal medicine vs. pediatrics) can be largely attributed to education on use and management of complications. Particularly, the IUD and implant require training to place correctly, and their placement procedures have inherent risks.
OB/GYN doctors are trained in the insertion of these devices as well as in the management of the complications that can arise from these procedures. Many family medicine, internal medicine and pediatric physicians are not trained at all or do not receive enough training in the insertion of the devices and also do not feel comfortable managing the known complications associated with the devices. IUD placement in teenagers can be more challenging based on the individual patient’s anatomy and comfort level with a vaginal exam, which may lead pediatricians to suggest other options.
This study brings up a lot of questions about future access to contraceptive options and the contraceptive services provided by different specialties of medicine and APPs. It finds that geographical and socioeconomic status impacts the contraceptive options available for patients. While OB/GYN doctors are more likely to accept Medicaid for contraceptive management, there are fewer concentrations of OB/GYN doctors, especially in rural areas.
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