Upstream
Improving Access to Contraception
Mark Edwards has been thinking about how to lift people out of poverty for a long time. His father managed to transcend it—and send three children to Harvard—but Edwards knows most people aren’t so lucky. For 25 years, he focused on preschool, education, and employment to expand opportunity for youth. But time and again, the young people he worked with found their lives derailed by the same problem.
"I became pregnant and dropped out of school and had to quit my job."
In the United States today, unplanned pregnancy is all too common. Half of pregnancies are unintended, amounting to 1.5 million unplanned children born every year. Among low-income women, the rates are far higher—five times that of upper-income women. An unplanned pregnancy can far too often lead young parents to drop out of school and/or the workforce, making it harder to climb the ladder of opportunity.
A Giant Gap—and the Chance to Close It
Federal policy provides women free access to the full range of birth control options, including long-acting reversible contraception (LARC), such as IUDs or the birth control implant. Unlike condoms and the pill, which are highly fallible, LARC requires no daily effort, lasts for three to 10 years, and has a less than one percent failure rate.
Yet, only 30 percent of clinics that serve poor populations offer LARC in a single visit. This is largely because their staffs aren’t trained to administer the devices and don’t know how to bill for them. Such training is hard to come by: in 2014, there were few, if any, providers.
More Than Birth Control
When seasoned health care administrator Renee McConey took the helm at The Door’s Adolescent Health Center serving New York City’s vulnerable youth, the health center was not offering LARC. She searched high and low for the training her staff needed, including hands-on training for medical providers, and came up empty—until she heard Peter Belden from Upstream speak at a NYC Department of Health family planning meeting. “They were just getting up and running and ready to partner with new agencies,” says McConey. “After the meeting, I was the first one in line to meet with Peter to see if they can help us at The Door with our training needs.”
Thanks to Upstream, McConey’s team is fully equipped to administer LARC, code and bill for LARC services, and counsel youth on their contraceptive options. Every staff member is trained to talk about contraception. In the waiting room, a birth control video runs in a loop, and educational materials are available throughout the health center. Each month, 15 – 20 percent of patients choose LARC, adding up to more than 1,600 to date.
But McConey sees an even more profound change at her health center. “It’s about having empathy and also making sure our young people have access to all birth control options, including LARC,” she explains. She credits Upstream with helping her staff become more client-centered, unbiased, and neutral in the way they present all birth control options including LARC, and more flexible with scheduling patients for LARC. “If they’re a few minutes late, walk in or want to add a LARC to their visit, we figure it out, and get it done in order to meet the needs of our clients,” says McConey.
When Edwards stumbled upon this gap, he knew he was onto a way to make a big difference in a remarkably short period of time. “It’s what women want themselves: access to best-in-class healthcare. Additionally, it saves millions of dollars in healthcare-related and other downstream costs,” says Edwards.
Full Speed Ahead
Edwards teamed up with Peter Belden, who had led the William and Flora Hewlett Foundation’s grantmaking for family planning and reproductive rights, to form Upstream. Together, they wrote a concept paper, which Edwards had on hand when he visited Bridgespan’s Boston office in the fall of 2014.
“It was striking that Upstream had that concept paper and such an ambitious vision right from the outset,” says Bridgespan manager Kristen Loureiro. “They weren’t telling a story about incremental growth. They were telling a story about really wanting to change things nationwide.”
"What we hope to do is create a healthcare system where women can get access to the full range of birth control methods in a single visit, with great counseling, so that women can really make informed choices about what works for them, with no administrative barriers.” says Edwards.
Upstream connected with Blue Meridian Partners, a philanthropic fund created by the Edna McConnell Clark Foundation (EMCF), which seeks to invest in grantees that can solve large-scale problems. Blue Meridian saw that Upstream had enormous potential for impact, but needed a more robust plan to achieve its vision. With Blue Meridian’s support, Bridgespan worked with Upstream to develop a plan to improve contraceptive care for the majority of the 20 million US women at highest risk of unplanned pregnancy. Together, Bridgespan and Upstream worked through every aspect of the business plan, from growth to budget to hiring, and made the key strategic choices that would set Upstream up to have national impact.
"So much of what we had to do, and what all nonprofits have to do, particularly in the beginning, is prioritize the urgent over the important. We were running hard, building a plane as we flew it. [Working with Bridgespan] gave us the chance to focus on the important. Here we had a set of really talented, thoughtful, analytical and, even more so, experienced people to help us look around the corner and force us to answer some questions that we just hadn't spent the time to think about."
The resulting plan has Upstream reaching more than one million women in five states in the next seven and a half years, as well as launching work in a second set of states. The ultimate goal: to put themselves out of business by ensuring all women have access to the birth control method of their choice, allowing them to plan if and when to become pregnant. The evidence shows Upstream’s efforts are working. In Delaware, where Upstream launched its first statewide initiative, women have access to—and are choosing—more effective contraceptive methods, contributing to an estimated 15 percent decrease in unplanned pregnancies among Title X family planning clients between 2014 and 2016. During this same time period there was just a 1.3 percent estimated decrease in unplanned pregnancies among Title X women nationwide.*
Moral Urgency
In 2017, Blue Meridian committed to invest $60 million in Upstream’s efforts. By then, Upstream had reached 160,000 women of reproductive age—and continues to grow at a breathless pace. “It would have been much easier, certainly, to be much more methodical about it, and be much more patient about it,” says Edwards. “I think we feel moral urgency and…the hard truth is there’s really nobody else doing what we’re doing.”
"Upstream is pursuing a too-rare strategy for scale. Instead of growing their evidence-based program from site to site, they asked: ‘What would it take to affect all of the women we are trying to reach in each state?’ Starting from that end goal and working backwards meant that they needed a lean intervention that was built for full scale from the outset. It also meant their learning and improvement agenda could be rapidly incorporated in their next rounds of growth."
As Upstream continues to navigate exponential growth and fundraising needs in a learn-as-you-go environment, Edwards has high hopes. “I genuinely believe this could be one of the great public health and opportunity wins of our lifetime,” he says.
* Source: Child Trends childtrends.org, Research Brief, March 2018 Publication #2018-05
Created: September 2018