Policy and Contraceptive Decision-Making: The Impact of the Dobbs Decision

Abstract

Introduction

Reproductive healthcare in the United States has been shaped by evolving state and federal policies. The 2022 Dobbs v. Jackson ruling marked a pivotal shift in reproductive health. Recent studies suggest an increase in clinician-patient discussions about long-acting reversible contraceptives (LARCs) in the post-Dobbs era. While research has explored some trends, data on the national impact of Dobbs on LARC utilization remains limited. This study aims to analyze LARC usage patterns in the U.S. before and after the ruling. We hypothesize that overall LARC utilization increased at both the 6-month and 1-year post-Dobbs time periods in response to shifting reproductive healthcare policy.

Methods

Using de-identified medical records from 68 healthcare organizations in the electronic health record analysis platform, TriNetX, two cohorts of patients were created. These cohorts were defined as the following: female sex, aged 15-49, with reproductive capacity, and who had an ambulatory care visit within the defined cohort period. The pre-Dobbs cohort was created using the aforementioned criteria occurring between June 23, 2021 and June 23, 2022; similarly, the post-Dobbs cohort was created with the criteria occurring between June 24, 2022 and June 24, 2023. To determine whether differences in LARC utilization were due to initial reactions to the decision, a 6 month cohort was created for comparison, with end dates 6 months after the beginning of the observation period (6 months pre-Dobbs: December 25, 2021 to June 23, 2022; 6 months post-Dobbs: June 24, 2022 to December 21, 2022). After 1:1 propensity-score matching by age and race, four patient cohorts were generated: a 6-month comparison cohort (N=3,525,585) and a 1-year comparison cohort (N=4,739,490). Outcomes included insertion of either an IUD or a subdermal contraceptive implant.

Results

The 6 months post-Dobbs cohort showed an increase in IUD insertions from 0.807% to 1.587% (RR=0.511, 95% CI [0.504- 0.519], and an increase in subdermal implant insertions from 0.146% to 0.304% (RR=0.481, 95% CI [0.465-0.497], p<0.0001).

Similarly, the 1-year post-Dobbs cohort showed an increase in IUD insertions from 0.953% to 1.436% (RR=0.664, 95% CI [0.656-0.672], p<0.0001) and an increase in subdermal implant insertions from 0.167% to 0.318% (RR=0.525, 95% CI [0.510-0.539], p<0.0001).

Conclusion

LARC utilization increased markedly in the year following the Dobbs v. Jackson decision. The immediate uptake in LARCs during the initial 6-month period highlights the critical role perceived access plays in individual reproductive healthcare decisions. The 1-year data indicate sustained but tapering demand. While IUDs remain the more commonly used LARC method, demand for subdermal implants during this period also increased significantly, possibly as a result of their less invasive placement, easier removal, or patient preference. As reproductive rights face uncertainty, the trend of seeking longer-term solutions underscores the need to ensure continued, equitable access to contraception options in order to protect reproductive autonomy in an evolving legal landscape.