COLUMBIA, S.C. — Last month, Akia Gayle gave birth to her third child. Sixteen hours later, while she was still in her hospital bed, a doctor implanted a matchstick-size plastic rod in her left arm because she did not want to have a fourth.
“To have it done right then and there — that’s good,” Ms. Gayle said. “I don’t want more kids.”
Ms. Gayle is one of thousands of women in South Carolina’s Medicaidprogram who have gotten long-acting contraception at an unusual moment — right after they give birth. The novel policy, which has since been adopted by at least 19 other states, covers long-acting contraception right after birth for women on Medicaid, the government health insurance for low-income Americans. It is intended to help answer one of the most vexing questions in public health: how to reduce unplanned pregnancy in the United States.
Nearly half of all pregnancies in the country are unplanned, and in a majority of those cases, the woman already has a child. Rates are at least twice as high for poor women. Yet contraceptive methods have never been better: Tiny implants and new, modern IUDs last for up to five years and are far more effective than condoms and the pill. The problem is that they are expensive and usually require several trips to the doctor, insurmountable hurdles for many low-income women.
be interacting with the health care system — at the birth of a child. It is also the moment she is most likely to be insured: Pregnant women who are poor and do not have insurance are put on Medicaid temporarily. Birth control is usually discussed in a checkup about six weeks after delivery, but a majority of women on Medicaid, which covers 57 percent of births in South Carolina, do not return, officials said. Nearly half of all births in the United States are covered by Medicaid.
The change seems to have done the unimaginable: connect large numbers of poor women with new methods of birth control that have the potential to give them a lot more say over when, and with whom, they have children. Since South Carolina started the policy in 2012, unplanned pregnancies have declined by 6 percent, and the state Medicaid office has saved $1.7 million.
Still, there are some who are leery of it, given the ugly history of forced sterilizations in the United States.
“I can’t put my finger on exactly why, but it makes me cringe,” said Dr. Joia Crear-Perry, an obstetrician in New Orleans who is the president of the National Birth Equity Collaborative, an advocacy group for black families. “It makes me think about control. Mistrust. The history of African-American women in this country.”
The policy is part of a broader set of changes transforming birth control in the United States. The pill has long been the most common, but it works only when women remember to take it. The new, long-acting methods, which include updated and less expensive intrauterine devicesand arm implants like Ms. Gayle’s, set the default to “not pregnant” until a doctor takes them out, a major change from the past and one that women have overwhelmingly chosen when offered the option for free in experiments in Missouri, Iowa and Colorado.
Taking note of the success that the South Carolina Medicaid office has had in boosting the use of long-acting contraceptives, the biggest private insurer in the state, Blue Cross Blue Shield, has started offering the same option to women who have just given birth. Nineteen other states — including Georgia, Iowa, Maryland, Massachusetts and Texas — have since made similar policy changes, according to the American Congress of Obstetricians and Gynecologists. This summer, the group recommended that other states do the same.
But last month, two women’s health groups, SisterSong and the National Women’s Health Network, published a statement urging caution: “Many of the same communities now aggressively targeted by public health officials for LARCs have also been subjected to a long history of sterilization abuse,” they said, speaking of long-acting reversible contraceptives.
Public health officials said they were working to address the concerns. “The words voluntary and reversible are very important,” said Dr. Lisa Waddell, the chief program officer of community health and prevention at the Association of State and Territorial Health Officials, which has been holding meetings and conference calls for states about long-acting contraception. “It’s important that women don’t feel coerced into something.”
Women’s health advocates argue that the methods empower women. Using them means women become parents only if they want to. And since single parenthood is a big driver of poverty, long-acting methods are a powerful tool to prevent it, according to Isabel Sawhill, a senior fellow at the Brookings Institution. Women covered by Medicaid are disproportionately more likely to be single parents, compared with women on private insurance, according to the Kaiser Family Foundation.
In South Carolina, doctors discuss the options for birth control long before the birth, during a prenatal visit. Which method, if any, is entirely up to the woman, state health officials say.
On a recent Tuesday, Dr. Chandler Finney, an obstetrician-gynecologist resident at Palmetto Health Richland, a large hospital in Columbia, was ticking off the long list of methods to Tiffany Hampton, 19, who recently found out she was pregnant.
“People your age tend to like this one,” she said, pulling a plastic model of a uterus with an IUD off a shelf. She pointed out that it was safe to use while breast-feeding. “It’s easy,” she added. “You don’t have to deal with it.”
Ms. Hampton, sitting in jeans and a T-shirt on an examining table, looked at it.
“I want to get one — I just have to choose which one,” she said.
Even though birth control was supposed to be free for women under the Affordable Care Act, many hurdles remain, and use has remained relatively low, compared with the pill.
That is changing. Recent legislation in California, Vermont, Maryland and Illinois requires long-acting methods to be included in contraception offerings by health plans, according to Elizabeth Nash, a senior state issues associate at the Guttmacher Institute. Advocacy groups are teaching doctors how to insert the devices and their clinics how to bill for them, a critical obstacle.
“Things have shifted so dramatically,” said Greta Klingler, a public health official in Colorado. “Every single state is really making efforts to increase access. I’m hopeful we’ve hit the tipping point.”
Giving a woman a long-acting contraceptive at the time of birth may seem obvious, but before South Carolina started doing it in 2012, it was rarely done, mostly because payment systems were not set up to cover it that way.
“She’s there, she’s definitely not pregnant because she just delivered,” said Dr. Judith T. Burgis, the chairwoman of the department of obstetrics and gynecology at Palmetto Health University of South Carolina Medical Group, a medical practice in Columbia. “It’s easier to do right then and there, before she gets home and has a newborn to take care of.”
The state has also streamlined the process of obtaining contraceptive devices for the broader population of women on Medicaid — not just those who are pregnant. Now women can get the device almost immediately after asking for one in a doctor’s office, instead of waiting weeks and making multiple trips.
Ms. Gayle, 28, a home health aide who is originally from Brooklyn, appreciated having the option to get the implant right away. Coming back to the doctor to talk about birth control would have meant borrowing a car, bundling her new baby and two other daughters into it, and driving 40 minutes. That was unlikely to happen, she said. She also liked that she could have it done and then forget about it.
“This right here is good,” she said, touching her arm, bandaged where the rod had been inserted. “You don’t have to remember to take anything. It’s just there.”