Telemedicine for Contraceptive Counseling During the COVID-19 Pandemic: Referral Patterns and Attendance at Follow-Up Visits

Table 1 shows the demographic and visit characteristics of patients included in the study. Of note, most patients were either Black or Hispanic, and more than half (60.4%) were publicly insured. Most telemedicine visits (93.5%) were conducted via phone.

Table 2 shows the characteristics of the patients who were referred for in-person visits, and who did or did not attend such visits within 30 days of referral. On univariate analyses, the only significant variable associated with attendance was age (p = 0.041). There was a trend toward referral reason being associated with attendance, but this did not meet statistical significance (p = 0.052).

Table 3 shows the results of a multivariable modified Poisson regression model with robust error variances. The covariates that were included in the final model were referral reason and age, as these were the only ones that reached statistical significance as per the backward selection strategy described earlier. The RR of attendance at an in-person visit within 30 days was 24% higher among patients referred for LARC removal compared with those referred for other reasons (RR 1.24, 95% confidence interval [CI] 1.08–1.69, p = 0.048). It was 29% lower among younger patients (age 18–25) compared with those in the reference category (age 26–35, RR 0.71, 95% CI 0.51–0.98, p = 0.035).

A total of 63 patients responded to the 6-month follow-up survey (37.3% response rate). There were no significant differences in terms of demographic or visit characteristics among patients who did and did not respond to the 6-month follow-up survey (Supplementary Table S1). As shown in Table 4, most (69.4%) survey respondents were still using the contraceptive method they had decided on at the telemedicine visit.

Many respondents were affected by the COVID-19 pandemic; notably, 22.2% lost their job, and 15.9% experienced the death of a friend or family member. When asked about their preferred visit type for their next contraception visit, about half (55.6%) opted for an in-person visit, whereas the rest opted for a phone (28.6%) or video visit (15.9%).

Discussion

In this study, we describe the referral patterns and outcomes of patients who sought contraceptive care during the COVID-19 pandemic and who were required to have telemedicine visits, with in-person referrals as needed. We found that more than a third of patients were not initially referred for in-person visits. Over the 6-month follow-up period, approximately one quarter of patients in the entire telemedicine cohort did not have any additional visits related to contraception.

At 6 months, almost 70% of patients were still using the method they decided on at the visit, and almost half said they would choose video or phone for their next contraception visit. Although the need for further contraception visits is an imperfect measure of whether telemedicine meets patients’ needs, these results suggest that telemedicine could be sufficient for many of those who are seeking comprehensive contraceptive care.

These findings are new to the literature, because studies that follow patients up after telemedicine visits are rare, and to our knowledge this has not been examined in the context of contraceptive counseling. We do know that the acceptability of telemedicine tends to be high for both patients and providers across various fields of medicine. In another analysis from this research project, for example, we found that patients are highly satisfied with telemedicine visits for contraceptive counseling, and that 63% said the initial telemedicine visit completely met their needs.²⁰

The findings of this analysis confirm that many patients are well served by telemedicine for contraceptive counseling. This is in line with other work on telemedicine in various areas of medicine, including medication abortion, which has demonstrated high patient and provider satisfaction rates.^24–27

In the realm of contraception, one study conducted in the United Kingdom found that patients who received contraceptive counseling via phone before an abortion visit were more likely to choose a highly effective contraceptive method than those who received counseling at the abortion visit,¹⁰ which raises the possibility that telemedicine could serve as a helpful adjunct to in-person visits for contraceptive counseling. However, that study does not assess the extent to which telemedicine alone can meet patients’ needs, as all patients were also scheduled for in-person visits.

Interestingly, most of the telemedicine visits our study were phone rather than video visits. This is in part because our hospital did not have an existing video platform when services first started during the pandemic. However, once the video platform was implemented, many patients chose phone over video visits, as discussed in our previous work.²⁰ As this preference for phone visits may have billing implications, it is worth examining further whether it is specific to our patient population, and how it may impact, if at all, the ability to meet patients’ needs remotely. Of note, our population comprises mostly women of color who reside in a poor borough, and our findings may be particularly relevant to other underserved populations.

One concern about telemedicine in the context of contraceptive care is whether these visits could be considered an extra step or barrier to accessing contraceptives, especially LARC. By analyzing attendance at in-person visits, we sought to examine whether patients who needed to be seen in-person would present for those visits, or whether they might get lost to follow-up after the telemedicine visit. It was encouraging to see that most patients did show within 30 days of referral, and that several others came between 30 days and 6 months.

That patients who sought LARC removals were more likely to attend suggests some patients may be particularly motivated to seek services, perhaps in the setting of contraceptive side effects or if they are seeking pregnancy. That younger patients were less likely to attend may raise concerns about the suitability of telemedicine for adolescent populations. However, adolescents likely have lower show rates regardless of visit type; at least one prior study examined no-shows to primary care appointments, for example, and found that patients who no-showed were younger than others.²⁸

This study has several limitations. First, its generalizability is limited by the particular pandemic circumstances in which it was conducted, and by the fact that most visits were phone rather than video visits. Also, there is no comparison group, so we cannot make any conclusions about how telemedicine visits compare with in-person visits for contraceptive counseling in terms of any of the outcomes we examined. However, given the context in which the study was carried out, it was not possible to have a control group.

Another limitation is that the outcomes we selected (such as additional clinical visits, show rates at in-person visits, and self-reported method continuation) were arbitrary, based on our theory of what it means for telemedicine to “meet patients’ needs” in this realm.

As far as we know, there are no standardized outcomes for this kind of research question. Further, we could not accurately measure unintended pregnancies, as not all patients were seeking contraception (some were seeking contraceptive discontinuation before pregnancy). This would have been a useful measure to determine whether unintended pregnancy rates are higher in those who receive counseling via telemedicine.

Finally, we did rely on a patient survey with a low response rate for some of our outcomes, which raises concerns about response bias. However, it is encouraging that respondents and non-respondents did not differ significantly in terms of demographic or visit characteristics.

This study also has strengths, including its prospective design, and its use of multiple modalities to collect patient outcomes, including chart reviews and survey responses. It also examines an underserved, mostly minority population that was heavily affected by COVID-19, as evidenced by the high proportion of patients who reported job loss, death of a friend or family member, and other tragic consequences of the pandemic. That this population had positive outcomes with telemedicine for contraceptive counseling is promising for the ability of this technology to address some of the health disparities that plague our health care system.

In conclusion, this study offers encouraging results that support the expansion of telemedicine for contraceptive counseling. It is essential that the ongoing use of this technology post-pandemic be examined, in a world where patients can self-triage between in-person and telemedicine visits.

Authors’ Contributions

The authors confirm that all authors of this article meet authorship criteria according to the International Committee of Medical Journal Editors in Roles and Responsibilities. B.M.S., E.E.L., and N.C.B. designed the study. B.M.S., A.S., and K.A. collected the data. All authors contributed to the article and approved the final version submitted.

Disclosure Statement

None of the authors have any conflicts of interest to disclose.

Funding Information

The study did not receive external funding but did receive internal funding from the Division of Family Planning in the Department of Obstetrics, Gynecology and Women’s Health at Montefiore Medical Center.

Supplementary Material

Supplementary Table S1