In 2018, the Virginia Department of Health implemented the Contraceptive Access Initiative (CAI) to increase access to hormonal contraceptives and Long-Acting Reversible Contraceptives (LARC) for low-income women. In this paper, we use encounter-level data on contraceptive choice in participating CAI clinics and county-level natality data from 2014–2021 to estimate relative changes in childbearing before and after the CAI. When comparing counties with CAI clinics in Virginia to counties in bordering states with publicly funded clinics, difference-in-differences estimates indicate that the CAI reduced birth rates in participating counties by 1.8–3.5 percent. Despite the success of the program in reducing unintended births, we note that this magnitude is less than half of the effect size of other similar, state-level programs. We present new evidence that this smaller effect is due to the existing high LARC take-up in Virginia as well as the substitution effects from other contraceptive devices, suggesting that policy environment and demand are important determinants for effectiveness

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