Employment Status, Contraceptive Use, and the ACA

Employment status was associated with long-acting reversible contraceptives (LARC) methods prior to the Affordable Care Act (ACA), but not after in non-Hispanic White women, according to a recent study¹.

About half of all US pregnancies are unintended, and half of these cases are seen in women not using a contraceptive. In many countries, an association has been found between employment and increased contraceptive use.

In the United States, about 50% of people receive health insurance from their employer and increased contraceptive use and lower fertility rates have been historically linked to employment in female patients. Other countries have seen associations between welfare reform and continued contraceptive access.

The ACA, which passed in 2010 and completed its planned roll out in 2014, implemented measures to reduce contraceptive loss during unemployment, such as mandated insurance coverage for contraception, employee and individual mandates to purchase insurance, Medicaid expansion, subsidies for purchasing insurance through health exchanges, and the option for children aged under 26 years to remain on parents’ insurance.

To determine the impact of the ACA on the association between employment status and LARC use, investigators conducted a cross-sectional study. Pre-ACA analysis was accomplished using survey data from 2006 to 2010, while post-ACA analysis was conducted using survey data from 2015 to 2017.

The National Survey of Family Growth (NSFG) was the survey used for both analysis cycles. The NSFG collects information on prior pregnancies, fertility status, use of contraception, marital status, family life, and men’s and women’s health.

Participants included women aged 15 to 44 years at risk for unintended pregnancy. Women who were sterile, infertile or had a partner who was infertile, abstinent for 3 months before the study, pregnant, trying to get pregnant, postpartum, or with incomplete data were excluded from the analysis.

Contraceptive use was the primary outcome of the study, measured as “Moderately effective or LARC use” or “Least effective or no contraception.” Moderately effective or LARC use included implants, oral contraceptive pills, intrauterine devices, patches, vaginal rings, injectable hormonal contraception, and diaphragm.

Employment status at the time of the survey was collected through “yes” or “no” responses. Covariates included age, race and ethnicity, insurance coverage, total family income level, education, and relationship status.

There were 5572 women in the pre-ACA sample and 2340 women in the post-ACA sample.Moderately effective contraception use was seen in 44.8% of women in the pre-ACA sample and LARC use in 8.4%. Most women in this sample were non-Hispanic White, privately insured, and not married.

Employment status differed significantly based on age, race and ethnicity, insurance, income, and education. Moderately effective contraception or LARC was more common in employed women.

A decrease in moderately effective contraceptive use from 44.8% to 32.7% and an increase in LARC use from 8.4% to 22% was observed in the post-ACA period. Race and ethnicity, marriage status, and insurance status were similar between participants from both samples.

An association was not observed between employment status and contraceptive method in the post-ACA period, but insurance, income, and education saw similar associations as the pre-ACA period. Race and ethnicity did not significantly impact outcomes in the employed and unemployed groups in the post-ACA period.

A significant effect modification was found from race and ethnicity on the association between employment status and contraceptive method. While non-Hispanic White women in the pre-ACA sample were 55% more likely to use moderately effective contraception or LARC when employed vs unemployed, this association was not found between other racial or ethnic groups.

There was a significant difference between moderatelyeffective or LARC use vs least effectiveor no contraception use based on employment status in the pre-ACA group, but this difference was not seen in the post-ACA group. This indicated ACA was effective in expanding contraception access for unemployed women.

This article originally appeared on Contemporary OB/GYN.

Reference

1. Lachiewicz M, Hailstorks T, Kancherla V. Employment status in the United States and use of long-acting reversible contraception or moderately effective contraception before and after the affordable care act: National survey of family growth 2006-2010 and 2015-2017. Prev Med Rep. 2023;33. doi:10.1016/j.pmedr.2023.102177