Influence of Medicaid expansion on short interpregnancy interval rates in the United States

Interpregnancy interval following missed abortion and the risk for preterm birth

OBJECTIVE

Short inter-pregnancy interval (IPI) of <18 months following a live birth, has been associated with adverse pregnancy outcome. This study aimed to evaluate whether a short IPI following a medically treated missed abortion (MA) poses similar perinatal risks in a subsequent pregnancy.

STUDY DESIGN

The retrospective analysis included patients with history of an MA at up to 10 weeks of gestation, treated with misoprostol (pgE1) only, and with a documented subsequent live pregnancy (2010-2022). 1110 Patients were allocated into two groups: IPI ≤18 months and IPI >18 months. The primary outcome was the risk for a spontaneous preterm birth (PTB) <37 weeks of gestation in the consecutive pregnancy. Secondary outcomes included maternal and neonatal adverse outcomes. Statistical analysis was performed using the Statistical Program for Social Sciences for Windows version 26 (SPSS Inc, Chicago, IL).

RESULTS

The cohort included 1,110 patients: 430 (38.74 %) patients with IPI <18 months and 680 (61.26 %) patients with IPI >18 months. The characteristics of the two groups were not significantly different. The rates of spontaneous PTB <37 and <34 weeks of gestation were significantly higher in the short vs. long IPI cohort (16.28 % vs. 7.06 % and 6.74 % vs. 5.0 %, respectively, p < 0.05). These patients also had a higher risk for Cesarean delivery (31.63 % vs. 23.34 %, p = 0.005) and postpartum hemorrhage (4.42 % vs. 2.06 %, p = 0.029) compared to patients with IPI >18 months. The observed differences remained statistically significant even after adjusting for potential confounding variables using multiple regression analysis. No other significant differences in neonatal or maternal outcomes were noted.

CONCLUSION

Short IPI (≤18 months) following a medical treatment MA may be associated with an increased risk of PTB, Cesarean delivery and PPH.

Comparing approaches to identify live births using the Transformed Medicaid Statistical Information System

OBJECTIVE

To evaluate the performance of different approaches for identifying live births using Transformed Medicaid Statistical Information System Analytic Files (TAF).

DATA SOURCES

The primary data source for this study were TAF inpatient (IP), other services (OT), and demographic and eligibility files. These data contain administrative claims for Medicaid enrollees in all 50 states and the District of Columbia from January 1, 2018 to December 31, 2018.

STUDY DESIGN

We compared five approaches for identifying live birth counts obtained from the TAF IP and OT data with the Centers for Disease Control and Prevention (CDC) Natality data-the gold standard for birth counts at the state level.

DATA COLLECTION/EXTRACTION METHODS

The five approaches used varying combinations of diagnosis and procedure, revenue, and place of service codes to identify live births. Approaches 1 and 2 follow guidance developed by the Centers for Medicare and Medicaid Services (CMS). Approaches 3 and 4 build on the approaches developed by CMS by including all inpatient hospital claims in the OT file and excluding codes related to delivery services for infants, respectively. Approach 5 applied Approach 4 to only the IP file.

PRINCIPAL FINDINGS

Approach 4, which included all inpatient hospital claims in the OT file and excluded codes related to infants to identify deliveries, achieved the best match of birth counts relative to CDC birth record data, identifying 1,656,794 live births-a national overcount of 3.6%. Approaches 1 and 3 resulted in larger overcounts of births (20.5% and 4.5%), while Approaches 2 and 5 resulted in undercounts of births (-3.4% and -6.8%).

CONCLUSIONS

Including claims from both the IP and OT files, and excluding codes unrelated to the delivery episode and those specific to services rendered to infants improves accuracy of live birth identification in the TAF data.

Understanding of Lactational Amenorrhea As a Contraceptive Method Among U.S. Pregnant Women

Introduction: The lactational amenorrhea method (LAM) of postpartum contraception is more effective than typical use of condoms or birth control pills. However, LAM may be underutilized due to incomplete perinatal counseling. Methods: We compared perceptions of the effectiveness of postpartum contraceptives including LAM among U.S.-born nulliparous pregnant women recruited using social media for a trial (NCT04601987). We used descriptive statistics to summarize data. Results: Of 760 individuals screened, 627 were invited to participate, and 451 (72%) were enrolled. Most (81%) had a college degree; 79% intended to breastfeed for at least 1 month. Only 8% believed exclusive breastfeeding reduces the chance of pregnancy "a lot" within 6 months of delivery and 2% indicated that exclusive breastfeeding is typically more effective than birth control pills or condoms. Compared with those planning to use other postpartum contraceptives, the 17% of respondents who planned to use LAM were more likely to know that breastfeeding delays return of menses (84% versus 44%, p ≤ 0.0001) and provides protection from pregnancy until menses return (54% versus 22%, p ≤ 0.0001). Although 25% of those planning to use LAM believed exclusive breastfeeding reduces pregnancy risk by "a lot," only 5% thought LAM is more effective than birth control pills and only 9% thought that it is more effective than condoms. Conclusions/Implications: First-time U.S. mothers are often unaware of breastfeeding's effects on menses and fertility. Clinicians providing counseling about postpartum contraceptive options should include more information on LAM.

Achieving Equity in Postpartum Contraception Access

Equitable access to contraception and contraceptive education has the potential to mitigate health disparities related to unintended pregnancy. Pregnancy and the postpartum window frequently offer reduced insurance barriers to healthcare, increased interaction with healthcare systems and family planning providers, and an opportune time for many individuals to receive contraception; however, there are additional considerations in method type for postpartum individuals, and contraceptive counseling must be thoughtfully conducted to avoid coercion and promote shared decision-making. This commentary reviews method-specific considerations and suggests priorities for achieving equity in postpartum contraceptive access.

Association of the affordable care act Medicaid expansions with postpartum contraceptive use and early postpartum pregnancy

OBJECTIVES

Before the Affordable Care Act (ACA), 55% of individuals giving birth with Medicaid lost insurance postpartum, potentially affecting their access to postpartum contraception. We evaluate the association of the ACA Medicaid expansions with postpartum contraceptive use and pregnancy at the time of the survey.

METHODS

We used 2012-2019 Pregnancy Risk Assessment Monitoring System data to estimate difference-in-difference models for the association of Medicaid expansions with the use of postpartum contraception (mean: 4 months postpartum): any contraception, long-acting reversible contraception, or LARC (contraceptive implant and intrauterine device), short-acting (contraceptive pill, patch, and ring), permanent, or non-prescription methods (condoms, rhythm method, and withdrawal), and pregnancy at the time of the survey. We examine low-income respondents overall and stratified by race and ethnicity.

RESULTS

We find that Medicaid expansion was associated with a 7.0 percentage point (95% CI: 3.0, 11.0) increase in postpartum LARC, a 3.1 percentage point (95% CI: -6.0, -0.2) decrease in short-acting contraception, and a 3.9 percentage point (95% CI: -6.2, -1.5) decrease in non-prescription contraceptive use overall. In stratified analyses, we find that increases in LARC use were concentrated among non-Hispanic White and Black respondents, with shifts in other postpartum contraceptives towards LARCs. Medicaid expansion was associated with a decrease in early postpartum pregnancy only among non-Hispanic Black respondents.

CONCLUSIONS

Medicaid expansions led to shifts from methods with a lower upfront out-of-pocket cost for people without insurance towards methods with the higher upfront out-of-pocket cost for people without insurance. These changes suggest that Medicaid expansion improved postpartum contraceptive access.

IMPLICATIONS

These findings indicate that postpartum uninsurance was a barrier to postpartum contraceptive access prior to Medicaid expansions under the Affordable Care Act. Medicaid expansions increased access to the full range of contraceptive methods.

Impact of Medicaid Expansion on Interpregnancy Interval

OBJECTIVES

Medicaid expansion under the Affordable Care Act (ACA) improved access to reproductive health care for low-income women and birthing people who were previously ineligible for Medicaid. We aimed to evaluate if the expansion affected the risk of having a short interpregnancy interval (IPI), a preventable risk factor for adverse pregnancy outcomes.

METHODS

We evaluated parous singleton births to mothers aged 19 or older from U.S. birth certificate data 2009-2018. We estimated the effect of residing in a state that expanded Medicaid access (expansion status determined at 60 days after the prior live birth) on the risk of having a short IPI (<12 months) using difference-in-differences (DID) methods in linear probability models. We stratified the analyses by maternal characteristics and county-level reproductive health care access.

RESULTS

Overall risk of short IPI was 14.9% in expansion states and 16.3% in non-expansion states. The expansion was not associated with a significant change in risk of having a short IPI (adjusted mean percentage point change 1.24 [-1.64, 4.12]). Stratified results also did not provide support for an association.

CONCLUSIONS

ACA Medicaid expansion did not have an impact on risk of short IPI. Preventing short IPI may require more comprehensive policy interventions in addition to health care access.