Beyond same-day long-acting reversible contraceptive access: a person-centered framework for advancing high-quality, equitable contraceptive care Kelsey Holt, ScD; Reiley Reed, MPH; Joia Crear-Perry, MD; Cherisse Scott; Sarah Wulf, MPH; Christine Dehlendorf, MD S ince 2000, when the first hormonal intrauterine device (IUD) was approved in the United States, there has been growing enthusiasm for long- acting reversible contraceptive (LARC) methods (IUDs and implants). Because LARCs are highly effective at preventing pregnancy, increasing their use has become a primary focus of efforts to achieve public health goals related to reducing unintended pregnancy. Efforts to expand contraceptive ac- cess have prioritized LARCs and have primarily focused on addressing cost, provider, and policy barriers to their provision. While this work has been, at least in part, motivated by the fact that these barriers have historically made LARCs disproportionately difficult to access, 1e6 efforts have often gone beyond addressing barriers to promoting LARCs as first-line contra- ception through marketing campaigns and a tiered-effectiveness counseling model that emphasizes effectiveness as the most important method attribute. 7e10 Many have raised concerns over un- intended consequences of such a heavy emphasis on LARC promotion for peo- ple’ s autonomy and trust in the health care system. This is particularly a concern among communities of color, youth, poor people, undocumented im- migrants, and incarcerated individuals for whom the experience of being directed, or coerced, into using partic- ular methods is nothing new but rather part of an ongoing legacy of reproductive oppression. 11e13 Even when providers do not intend to be directive, an emphasis on LARCs in programmatic work or counseling can be experienced as pressure. 14,15 Furthermore, promot- ing LARCs as the ideal methods (in counseling or marketing), and assuming that barriers to access are the only reason people do not use them, runs the risk of steering people away from methods that might be most effective for them and perpetuating understandable distrust in family-planning providers and programs. Over the last several years, there has been increasing recognition that, to support patient autonomy, efforts to expand contraceptive access must focus on making all methods accessible. There is also a need to recognize that meeting individuals’ contraceptive needs cannot be limited to ensuring financial and same-day access to contraception. To meaningfully support reproductive au- tonomy with contraceptive services, it is imperative to also address the range of factors that influence whether in- dividuals have the information and support needed to understand their bodies and seek care, whether they receive respectful care, and whether they are able to effectively use contraception when desired. 1. A person-centered framework for high-quality, equitable contraceptive care This growing recognition of the need to move beyond a siloed focus on LARCs and financial barriers provides an op- portunity for a next generation of con- traceptive access efforts to do more. Such work can build on past programmatic and policy successes related to LARC provision and expand to addressing a THE PROBLEM: Efforts to expand contraceptive access in the United States over the last decade have predominantly focused on long-acting reversible contraceptive methods, with relative neglect of other aspects of contraceptive access and resulting failure to ensure reproductive autonomy. THE SOLUTION: We define a framework that policymakers, program implementers, and researchers can use as a blueprint for considering a broader range of factors influencing equitable access to high-quality, person-centered contraceptive care and identifying potential solutions. From the Departments of Family and Community Medicine (Drs Holt and Dehlendorf, Ms Reed, and Ms Wulf), Obstetrics, Gynecology, and Reproductive Sciences (Dr Dehlendorf), and Epidemiology and Biostatistics (Dr Dehlendorf), University of California, San Francisco, National Birth Equity Collaborative (Dr Crear Perry), New Orleans, LA, and SisterReach (Ms Scott), Memphis, TN. Received Aug. 17, 2019; revised Oct. 17, 2019; accepted Nov. 5, 2019. This study was supported by funds from the David and Lucile Packard Foundation. The Packard Foundation played no role in the development of the framework presented in this Call to Action. The authors report no conflict of interest. Corresponding author: Kelsey Holt, ScD. kelsey. holt@ucsf.edu 0002-9378 ª 2020 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/). https://doi.org/10.1016/j.ajog.2019.11.1279 S878 American Journal of Obstetrics & Gynecology APRIL 2020 Call to Action ajog.org