Immediate postpartum, long-acting reversible contraceptive use among the Emergency Medicaid population: continuation rates and satisfaction

Postpartum Expansion of Emergency Medicaid is Associated with Increased Receipt of Recommended Glycemic Screening and Care

Oregon expanded Emergency Medicaid coverage to 60 days of postpartum care in 2018, facilitating ongoing care for conditions such as gestational diabetes. We linked Medicaid claims and birth certificates from 2010 to 2019 in Oregon and South Carolina, which did not expand postpartum care. We used a difference-in-difference design to measure the effects of postpartum care coverage among Emergency Medicaid recipients with gestational diabetes. Primary outcomes were receipt of recommended glucose tolerance testing and new diagnosis of Type 2 diabetes. Our sample included 2,270 live births among a predominantly multiparous, Latina population. Postpartum coverage was associated with a significant increase in receipt of a recommended glucose tolerance test (23.1 percentage points, 95% CI 16.9-29.3) and in diagnosis of Type 2 diabetes (4.6 percentage points, 95% CI 3.3-65.9). Expansion of postpartum coverage increased recommended screenings and care among Emergency Medicaid enrollees with pregnancies complicated by gestational diabetes.

Medicaid Reimbursement Program for Immediate Postpartum Long-Acting Reversible Contraception Improves Uptake Regardless of Insurance Status

OBJECTIVE

To evaluate whether a Medicaid reimbursement program for immediate postpartum long-acting reversible contraception (LARC) is associated with an increased rate of LARC uptake.

STUDY DESIGN

We conducted a retrospective cohort study comparing patients who delivered at a large, urban, tertiary medical center one year before and after Missouri Medicaid coverage changed to reimburse immediate postpartum LARC in October 2016. Patients were identified through the electronic medical record and excluded if they delivered prior to 24 weeks gestation or had a contraindication to immediate postpartum LARC. The primary outcome was placement of immediate postpartum LARC, which we examined overall and stratified by insurance type. We used multivariable logistic regression to determine the impact of the policy change while adjusting for appropriate confounders.

RESULTS

A total of 6,233 eligible patients delivered during the study period: 3,105 before and 3,128 after the change in reimbursement for immediate postpartum LARC. Patients delivering after the policy change were more likely to be Hispanic, have commercial insurance or be uninsured, and have a BMI >30. Placement of immediate postpartum LARC increased from 0.7% pre- to 9.7% post-policy change (aOR 15.6; 95% CI 10.1-24.2). In our stratified analysis, immediate postpartum LARC uptake increased for patients with Medicaid (aOR 15.8; 95% CI 9.9-25.4) and commercial insurance (aOR 9.7; 95% CI 3.0-31.8).

CONCLUSION

The change in Missouri Medicaid reimbursement for placement of immediate postpartum LARC had systemic impact with an increase in postpartum LARC uptake in all patients, regardless of insurance provider.

IMPLICATIONS

Insurance reimbursement has the power to influence hospital policy and patient care. Overall, changes to Medicaid reimbursement increased access to postpartum LARC for all patients at a large academic institution, regardless of insurance status.

Concordance of Desired and Administered Postpartum Contraceptives among Emergency and Full Scope Medicaid Patients

OBJECTIVE

To determine if concordance of contraceptive preference and uptake differ between postpartum recipients of emergency versus full scope Medicaid.

STUDY DESIGN

We performed a historical cohort study of patients who delivered at a safety-net hospital in Denver, Colorado in 2016. In our public system, all patients had access to immediate postpartum tubal ligation and all forms of reversible contraception in outpatient clinics. We used data from electronic health records to compare contraceptive preferences and uptake between patients with full scope and emergency Medicaid at hospital discharge and by 12 weeks postpartum. We then compared contraceptive concordance (use of the same method as desired during delivery admission) between the groups at time of postpartum discharge and by 12 weeks postpartum.

RESULTS

We examined 693 women; 349 (50.1%) had emergency Medicaid and 344 (49.9%) had full scope Medicaid. The mean age at delivery was 27.9 years, and most patients were Hispanic (74%). Women with emergency Medicaid were less likely to receive their desired method of postpartum contraception before hospital discharge (53.6% vs. 66.9%; p < .01). One-half of the patients with emergency Medicaid who did not receive their desired method of immediate postpartum contraception were unable to obtain it based on insurance ineligibility. By 12 weeks postpartum, the rates of concordance did not differ by insurance status: 52.4% of patients with emergency Medicaid and 55.2% of patients with full scope Medicaid received their desired method of contraception (p = .46).

CONCLUSIONS

Emergency Medicaid recipients, largely recent and/or unauthorized immigrants, have high demand for highly effective postpartum contraceptives. Although emergency Medicaid recipients initially had lower rates of receipt of their desired contraceptive during the hospital stay compared with those with full scope Medicaid, they ultimately had similar concordance rates by 12 weeks postpartum. We suspect this finding was in part due to free access to all methods of contraception in our outpatient clinics during the postpartum course. Systemic barriers should be reduced to ensure better access to postpartum contraceptives for all patients, regardless of insurance coverage, to improve reproductive equity.

Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care

IMPORTANCE

Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid.

OBJECTIVE

To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021.

EXPOSURES

Medicaid coverage of postpartum care.

MAIN OUTCOMES AND MEASURES

Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery.

RESULTS

The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.

Implementing immediate postpartum contraception: a comparative case study at 11 hospitals

Background

Immediate postpartum long-acting reversible contraception (LARC) is an evidence-based practice, but hospitals face significant barriers to its adoption. Our objective was to examine how organizational context (e.g., size, employee attitudes toward the clinical practice) and implementation strategies (i.e., the actions taken to routinize a clinical practice) drive successful implementation of immediate postpartum LARC services, with a goal of informing the design of future implementation interventions.

Methods

We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 US maternity hospitals. In 2017–2018, we conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research. Qualitative measures of implementation success included stakeholder satisfaction, routinization, and sustainability of immediate postpartum LARC services. Qualitative content analysis and cross-case synthesis explored relationships among organizational context, implementation strategies, and implementation success.

Results

We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. Successful implementation required three essential conditions: effective implementation champions, an enabling financial environment, and hospital administrator engagement. Six other contextual conditions were influential: trust and effective communication, alignment with stakeholders’ professional values, perception of meeting patients’ needs, robust learning climate, compatibility with workflow, and positive attitudes and adequate knowledge about the clinical practice. On average, sites used 18 (range 11-22) strategies. Strategies to optimize the financial environment and train clinicians and staff were commonly used. Strategies to plan and evaluate implementation and to engage patients emerged as promising to address barriers to practice change, yet were often underused.

Conclusions

Implementation efforts in maternity settings may be more successful if they select strategies to optimize local conditions for success. Our findings elucidate key contextual conditions to target and provide a menu of promising implementation strategies for incorporating recommended contraceptive services into routine maternity practice. Additional prospective research should evaluate whether these strategies effectively optimize local conditions for successful implementation in a variety of settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00136-7.