Reproductive Health Services Expanded During Pandemic but Inequities Persist

August 08, 2022

When the COVID-19 pandemic began—and non-emergent healthcare visits were limited—the need for greater access to and scope of virtual sexual and reproductive healthcare services increased dramatically. Telehealth and virtual healthcare services have demonstrated a variety of benefits compared to traditional in-person care, including addressing some of the most pervasive barriers to patients being able to access healthcare: time off work, transportation, and childcare. These services have increased access to providers, eased workflows and infection protection for clinical staff, and reduced interruptions in care for many patients.

Temporary changes to state and federal regulations, payment policies, and increased uptake of telehealth technology during the pandemic expanded access to reproductive health services, including delivery of care to pregnant women via telehealth services, at-home contraceptive method counseling, and virtual sexually transmitted infection (STI) care. These services have the potential to mitigate adverse health outcomes and expand reproductive autonomy but payment, regulatory, and technological barriers prevent permanent and widespread access.

The COVID-19 pandemic created unique challenges for in-person healthcare services, including contraceptive care, resulting in innovations in service delivery to ensure that patients can access the birth control method of their choice even if they are unable to receive in-person care. One example category is telecontraception platforms, which allow patients to access birth control via online health questionnaire. After a health professional reviews the medication request, they can prescribe the contraception to be delivered to the patient’s home or picked up at a local pharmacy.

Insurance coverage of these services is limited but, as of February 2022, at least 12 state Medicaid programs cover telecontraception services. Interest in self-administration of the Depo Provera shot (otherwise known as Depo SubQ) grew during the pandemic, as it allows patients to continue to receive their birth control method of choice even when they cannot physically access a clinic. While not all health insurance plans cover the self-administered Depo SubQ—and some pharmacies do not carry it or will not dispense it without explicit instructions from a medical provider—states are exploring ways to increase access to and coverage of this at-home option.

To further increase access to contraception, some states are also looking to expand the role of pharmacists. The advent of pharmacist-prescribed contraceptives began prior to the pandemic, but many states are advancing legislation in this area to increase access to these medications and reduce unnecessary exposure in healthcare settings due to COVID-19. For example, South Carolina passed a law in May 2022 allowing patients 18 years and older to get birth control pills and some forms of self-administered hormonal contraception through a pharmacist, including the provision of the Depo SubQ shot. South Carolina joins seventeen other states and Washington, D.C. in allowing this flexibility to patients.

Several mobile applications and online services offer STI testing, services which were expanded since the beginning of the pandemic. These platforms offer at-home collection kits that are mailed to a lab for testing. Some positive results prompt a patient to seek in-person care (e.g., HIV or syphilis) while others offer consultation and prescription services via the phone or an in-app chat system. Not only does at-home STI testing protect against unnecessary exposure to COVID-19 and other illnesses, but it also provides an important medical service for those who may not feel comfortable seeking in-person care due to stigma or privacy concerns.

As part of STI care, the pandemic increased attention to Expedited Partner Therapy (EPT), a harm reduction strategy that allows for the treatment of the patient’s partner without requiring a separate visit. EPT reduces the rate of repeat STIs and is recommended by CDC. While there are barriers with insurance coverage and prescribing, EPT provides a unique opportunity to treat STIs. The New York Department of Health lists EPT has an exception to the electronic prescribing mandate, allowing providers to give patients who test positive for an STI a paper prescription for medication to treat their partner in the cases of chlamydia, gonorrhea and trichomoniasis.

As a direct result of the declared Public Health Emergency, state Medicaid programs reimbursing for maternal telehealth services expanded from 19 to all 50 states and Washington, D.C. Several of these Medicaid programs also began covering audio-only visits at the beginning of the pandemic. Some states have made these and other telehealth-related policy changes permanent. For example, the Governor of Delaware signed the Telehealth Access Preservation and Modernization Act of 2021 into law in June 2021. This act extends the COVID-19 telehealth legislation allowing providers to treat patients who they have never seen in-person and allows telehealth appointments over the phone, thus reducing the burden on those who do not have access to both audio and video technology.

Several states (NH, AK, NY, GA) created or expanded upon previous guidance and tools to better equip doulas to provide virtual pregnancy support. Overall, equipping doulas and midwives with telehealth access bolsters the maternity workforce and creates opportunities for more equitable solutions for underserved communities and improves health outcomes. Furthermore, doula and midwifery groups developed guidance documents and toolkits on how to best engage with patients via telehealth.

Looking Ahead

Despite advancements made to coverage, technology, and the healthcare workforce during the pandemic, states are still facing several challenges in delivering accessible, affordable, and equitable virtual care to their communities. Several barriers must be addressed, including how to enhance telehealth services while many individuals lack access to high-quality and reliable internet service. Adequate insurance coverage and culturally appropriate communication materials about available services must also be prioritized to reduce inequities in care. As states work to address these and other barriers around reproductive healthcare, it is critical to ensure individuals have access to reliable, effective contraception and reproductive health plans that meet their needs and preferences and promote positive health outcomes.