No one enjoys going in to see the doctor. Our current healthcare system features long wait times, high out-of-pocket costs and even higher opportunity costs, like having to take a half day off work for a 15-minute appointment.

In the wake of the COVID-19 pandemic, things are starting to change. We are witnessing a rapid emergence of telemedicine options for care, as the crisis has forced healthcare institutions to re-evaluate their delivery models. But is telemedicine enough?

My patient “Sarah” would say it is not.

Sarah had her contraceptive implant removed when she scheduled her surgical sterilization for March 2020. When the pandemic halted all “elective procedures,” her surgery was cancelled. She attempted to make an appointment to restart birth control, but by the time she was able to, in June 2020, she was 6 weeks pregnant. Sarah had a routine first trimester ultrasound in July, where she learned that her pregnancy was complicated by multiple fetal anomalies and was later diagnosed with Turner’s syndrome, a chromosomal disorder. She underwent an uncomplicated termination of pregnancy in mid-August and was rescheduled for surgical sterilization in the week to follow. The day before her scheduled surgery, her routine COVID-19 test came back positive, and her sterilization was cancelled again.

Unfortunately, Sarah is not alone. One in three women in the United States, disproportionately Hispanic (45%) and Black (38%), report a delayed or cancelled visit for their reproductive health due to the COVID-19 pandemic. Despite the improvements in telemedicine availability during the pandemic, 75% of patients state that their clinician continues to require an in-person visit to obtain a refill for a birth control pill, patch or ring.

Despite the improvements in telemedicine availability during the pandemic, 75% of patients state that their clinician continues to require an in-person visit to obtain a refill for a birth control pill, patch or ring.

A patient who uses the birth control shot depot-medroxyprogesterone acetate (DMPA), also known as Depo-Provera, must be seen by a nurse for their intramuscular injection every three months. Similarly, a postpartum patient desiring a long acting reversible contraception (LARC) method, including intrauterine devices and the subdermal implant, often cannot obtain one unless they have an in-person postpartum visit, because in most states, insurance will not cover devices placed immediately after childbirth.

COVID-19 has forced us to alter the way we practice medicine, bringing the question “is it necessary for this visit to be in person?” to the forefront of every patient encounter. In addition to the healthcare consequences of COVID-19, there have been deep financial repercussions. Widespread closures and lockdowns slowed virus transmission, but also caused significant job loss, disproportionately affecting Black and Latinx women. While community recovery will be complex, one straightforward support to women in the wake of the pandemic would be to improve contraceptive delivery, given that pregnancy decreases a person’s earnings and accessing contraception increases earning power.

Here are three opportunities to do so.

1. Urge pharmaceutical companies to make short-acting hormonal methods of contraception available over the counter

Even prior to the pandemic, a national survey showed that 29% of those who tried to obtain a prescription for a hormonal method of contraception had problems accessing the initial prescription or the refill. This number likely increased with COVID-19-related restrictions on ambulatory care given the “non-essential” nature of contraception visits. 

Data supports the safety of patient self-screening for contraindications to hormonal contraception. Provider and patient screening results in agreement over 95% of the time and in cases of discrepancy, women were more conservative than the healthcare providers in identifying themselves as having a contraindication when they really did not. Over the counter availability of the contraceptive pill, patch and ring will eliminate an unnecessary, non-essential visit while increasing access to these forms of contraception.

2. Advocate for insurance coverage of self and pharmacy administration of DMPA

DMPA is an injectable contraceptive that is administered every three months through an injection either into muscle (intramuscular) or under the skin (subcutaneous). Both methods of injection are equally effective, but only the injection under the skin can be self-administered. Due to inconsistent insurance coverage for DMPA injections under the skin, the requirement to go into a doctor’s office for regular intramuscular injections continues to be a barrier to access. 

Legislators in California removed this barrier during the COVID-19 pandemic by utilizing a waiver to approve DMPA injections under the skin. A preliminary implementation study showed successful initiation of self-administered DMPA. Further expansion of coverage for DMPA under the skin injections will help patients maintain consistent use of the medication. 

Additionally, allowing pharmacists to administer DMPA could ensure increased access for those who do not feel comfortable with self-injections.

Using the same infrastructure that was put into place to allow many pharmacies to administer the COVID vaccine, we could easily include DMPA administration as a pharmaceutical service.

Using the same infrastructure that was put into place to allow many pharmacies to administer the COVID vaccine, we could easily include DMPA administration as a pharmaceutical service.

3. Support expansion of insurance coverage for postpartum LARC

LARC methods are the most effective forms of contraception and they can be placed by a provider during the hospital admission following childbirth. Yet, one study found that only 60% of those who desire LARC postpartum actually obtain it. Even for those who do, the average time from delivery to placement of the LARC is 60.5 days. A major barrier to placement of LARC during the childbirth admission is the lack of reimbursement for the device and the procedure by public and private insurers. Medicaid reimbursement for the LARC device and the insertion procedure in the immediate postpartum period is only available in approximately 18 states. Thus, most patients who desire postpartum LARC must wait until they have an in-person postpartum visit for the costs of placement to be covered. Expanding insurance coverage for postpartum LARC will increase access for mothers with newborns by eliminating the need for an in-person postpartum visit, helping them achieve their desired birth spacing and avoid unplanned pregnancies.

The barriers Sarah encountered in March of 2020, when her surgery was first cancelled, resulted not from an absence of contraceptive options but from the lack of access to the plethora of options in a timely fashion. One can’t help but wonder if her story would have been different if she had access to the birth control pill over-the-counter or could have self-administered DMPA under the skin. 

COVID-19 challenged us to rapidly adapt our health care delivery model. As we rise to the occasion, let’s ensure that we don’t leave reproductive health behind.