In 2019, the New Hampshire Children’s Health Foundation (NHCHF) implemented a strategic grantmaking model aimed at strengthening protective factors and early intervention practices to prevent or ameliorate adverse childhood experiences (ACEs). One component of the model is the reduction of unintended pregnancy through increasing awareness and availability of all contraceptive methods so that people are empowered to confidently decide if and when they want to parent. To inform the development of this work, NHCHF, joined by a funding partner, supported an assessment of the current landscape of sexual and reproductive health care services in New Hampshire. The overarching objectives of the assessment were to:
- Understand the current landscape of access to and education about contraceptive methods in New Hampshire; and
- Examine the barriers that individual patients face in accessing contraceptives and other sexual and reproductive health care.
Assessment methods included a review of secondary data, a review of current literature, a survey of health care providers, and a population-based survey of health care consumers. Initially, the assessment focused on the availability and accessibility of Long-Acting Reversible Contraceptives (LARC) over other birth control methods, due to their high efficacy and potential for extended use without user action. However, findings from the literature review illuminated the potential risk of reinforcing limited contraceptive choice and coercive practices through LARC-specific initiatives that target priority populations (often Black, Latina, or Indigenous women, poor women, or individuals with disabilities) and that reduce access to other birth control methods. To address the potential for harm, the decision was made to expand the assessment’s focus to include all birth control methods and access to sexual and reproductive health services more broadly.
In September 2021, the New Hampshire Executive Council elected to reject family planning contracts for three clinic sites. According to the Planned Parenthood New Hampshire Action Fund, the three sites that were defunded provide care to approximately 80% of patients that received reproductive healthcare covered by the state Family Planning Fund. While the data collection of this assessment occurred prior to the decision, its impact should be considered in relation to key findings and recommended strategies.
Respondents to the population-based consumer survey were asked to indicate their use and awareness of various birth control methods. Respondents most frequently reported that they currently use birth control pills (26.5%), external/male condoms (24.1%), and withdrawal (or the “pull out” method) (21.7%). While close to half of respondents indicated that they were familiar with hormonal and non-hormonal IUDs, only 8.4% indicated they currently use a hormonal IUD, while only 4.8% currently use a non-hormonal IUD. Respondents most often reported to have never heard of the FDA Approved Birth Control App (18.1%), contraceptive sponge (13.3%), and cervical cap (12.1%).
The provider survey asked respondents about their confidence in their knowledge of LARC-related topics, including insertion and removal procedures, side effects, and contraceptive efficacy of the methods. Across IUD- and implant-related topics, a majority of respondents reported being moderately or completely confident. Respondents most often reported being moderately or completely confident in contraceptive efficacy of IUDs (98.0%) and side effects of IUDs (94.2%). The topic area that had the largest portion of respondents who reported being not confident at all in was pertaining to implant insertion and removal procedures (21.6%).
The cost of care emerged as a key barrier to sexual and reproductive health care services across the groups looked at for this assessment, rising from both consumer and provider surveys. While direct comparisons between the provider and consumer surveys cannot be made, there were notable differences between provider perception of patient barriers and consumers’ report of their own experiences, including patient fear of procedures and experience of language barriers.
While experiences of discrimination varied between subgroups, gender and sexuality did emerge as factors in those experiences. Of consumer survey respondents who reported experiencing some form of discrimination while accessing sexual and reproductive health care, over half attributed their experiences to their gender or gender identity. Additionally, LGBTQ+ respondents were more likely to report experiences of discrimination, when compared to other respondents. Unfriendly providers or office staff also emerged as a key barrier for LGBTQ+ respondents accessing these services.
Patient experiences with feeling pressured to use or not use a specific birth control method also arose as a key finding from the assessment, with birth control pills, cervical caps, and IUDs being the methods that respondents most frequently indicated as experiencing pressure around. In addition to experiences of discrimination and coercion, a majority of respondents indicated having at least one ACE. It is important to understand these experiences of trauma that patients may bring with them and that may influence their health or health care seeking behaviors.
Following the completion of this assessment, the following strategies are recommended as potential next steps for this work:
- Provide “Trauma 101” and/or trauma informed care trainings for providers and staff in settings that provide sexual and reproductive health care services
- Focus groups or interviews with key populations to further understand assessment findings and identify potential strategies. Potential populations for further data collection could include:
o Health care providers or administrators
o Staff from the New Hampshire Family Planning Program
o Consumers from specific subgroups of interest (e.g., young adults)
• Identify and fund opportunities for health care providers and/or health center staff training on topics related to assessment findings, such as:
o Identifying and addressing bias in care delivery
o Birth control counseling approaches that support patient choice and limit feelings of pressure or coercion
o LARC insertion and removal procedures