Association for Public Policy Analysis & Management

Delaware has the highest rate of unintended pregnancy in the United States. In 2015, the state partnered with Upstream USA to launch an ambitious program aimed at increasing access to the full range of contraceptives, including long-acting reversible contraceptives (LARCs). Delaware Contraceptive Access Now (Del-CAN) changed the way contraceptives were paid for, increased financial support for publicly funded clinics, delivered clinical and business operations training and technical assistance to providers, and fielded a public awareness campaign to direct patients to trained providers with capacity to deliver LARCs. This paper examined the effect of Del-CAN on the contraceptive method types used by female Title X clients at risk of unintended pregnancy.

We used state-by-year administrative data from restricted-use versions of the 2008-2017 Family Planning Annual Report (FPAR) which covered 7 pre-period years (2008-2014) and 3 post period years (2015-2017). The FPAR, compiled by the Department of Health and Human Services’ Office of Population Affairs, tracks primary contraceptive method types and other characteristics of Title X clients. We merged these data with state-level demographic characteristics from the American Community Survey and measures of the policy environment (e.g. Medicaid expansion and abortion restrictions) from the Kaiser Family Foundation and the Guttmacher Institute.

Using difference-in-differences models we estimated the effect of Del-CAN on the age-group specific use of permanent methods (male and female sterilization), LARCs (implant and IUD), moderate methods (pill, patch, ring and injectable), less effective methods (e.g. barrier methods), and non-use. Control states included all other states and DC and we investigated the robustness of our results to a more limited set of control states. Models included state fixed effects, year fixed effects, state-specific trends, Medicaid expansion and other policy indicators, and state-by-year demographics. Statistical inference was obtained from a bootstrap. To account for unknown method types in the FPAR, we allocated the unknown to a specific method type using a multiple imputation approach and compared results under varying assumptions about the unknown.

Our preferred models suggests that Del-CAN increased LARC use by adults (age 20+) by a statistically significant 2.9 percentage points, a 33% increase from baseline. Estimates ranged from 2.2 to 5.9 percentage points, depending on our approach to unknown values. We also found significant declines to contraceptive sterilization. We did not find statistically significant effects to other method types, however, estimates were imprecise. Our findings suggest that over the first 3 years of the program, Del-CAN was successful at increasing use of LARCs. Our results have important implications for other states considering comprehensive family planning reforms.