Medicaid and receipt of interval postpartum long-acting reversible contraception

Implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning, a mixed-methods systematic review

BACKGROUND

Post pregnancy family planning includes both postpartum and post-abortion periods. Post pregnancy women remain one of the most vulnerable groups with high unmet need for family planning. This review aimed to describe and assess the quality of the evidence on implementation strategies, facilitators, and barriers to scaling up and sustaining post pregnancy family planning.

METHODS

Electronic bibliographic databases (MEDLINE, PubMed, Scopus, the Cochrane Library, and Global Index Medicus) were searched from inception to October 2022 for primary quantitative, qualitative, and mixed method reports on scaling up post pregnancy family planning. Abstracts, titles, and full-text papers were assessed according to the inclusion criteria to select studies regardless of country, language, publication status, or methodological limitations. Data were extracted and methodological quality assessed using the Mixed Methods Appraisal Tool. The convergent integrated approach and a deductive thematic synthesis were used to identify themes and sub-themes of strategies to scale up post pregnancy family planning. The health system building blocks were used to summarize barriers and facilitators. GRADE-CERQual was used to assess our confidence in the findings.

RESULTS

Twenty-nine reports (published 2005-2022) were included: 19 quantitative, 7 qualitative, and 3 mixed methods. Seven were from high-income countries, and twenty-two from LMIC settings. Sixty percent of studies had an unclear risk of bias. The included reports used either separate or bundled strategies for scaling-up post pregnancy family planning. These included strategies for healthcare infrastructure, policy and regulation, financing, human resource, and people at the point of care. Strategies that target the point of care (women and / or their partners) contributed to 89.66% (26/29) of the reports either independently or as part of a bundle. Point of care strategies increase adoption and coverage of post pregnancy contraceptive methods.

CONCLUSION

Post pregnancy family planning scaling up strategies, representing a range of styles and settings, were associated with improved post pregnancy contraceptive use. Factors that influence the success of implementing these strategies include issues related to counselling, integration in postnatal or post-abortion care, and religious and social norms.

TRIAL REGISTRATION

Center for Open Science, OSF.IO/EDAKM.

Increasing Access to Intrauterine Devices and Contraceptive Implants: ACOG Committee Statement No. 5

Everyone who desires long-acting reversible contraception should have timely access to contraceptive implants and intrauterine devices. Obstetrician-gynecologists and other reproductive health care clinicians can best serve those who want to delay or avoid pregnancy by adopting evidence-based practices and offering all medically appropriate contraceptive methods. Long-acting reversible contraceptive devices should be easily accessible to all people who want them, including adolescents and those who are nulliparous and after spontaneous or induced abortion and childbirth. To achieve equitable access, the American College of Obstetricians and Gynecologists supports the removal of financial barriers to contraception by advocating for coverage and appropriate payment and reimbursement for all contraceptive methods by all payers for all eligible patients.

Shared Decision-Making: The Way Forward for Postpartum Contraceptive Counseling

There are multi-level barriers that impact uptake of postpartum contraception and result in disparities, including clinical barriers such as provider bias. Fortunately, clinicians have direct control over their contraceptive counseling practices, and thus reducing structural barriers is actionable through high quality contraceptive counseling that equips patients with the knowledge and guidance they need to fulfill their reproductive desires. Yet, many commonly employed contraceptive counseling strategies, like One Key Question and WHO tiered contraceptive counseling, are not patient-driven, do not account for the important nuances of contraceptive choices, and are not focused specifically on the postpartum period. Given the history of eugenics and reproductive coercion in the US, supporting patient through their contraceptive decision-making process is especially vital. Additionally, contraceptive preferences vary based on patient-level factors and fluctuate over time and counseling should account for such differences. Shared contraceptive decision-making occurs when patients provide input on their values, desires, and preferences and clinicians share medical knowledge and evidence-based information without judgement. This approach is considered the most ethically sound form of counseling, as it maximizes patient autonomy. Shared decision-making also has clinical benefits, including increased patient satisfaction. In sum, shared contraceptive decision-making should be universally adopted to promote ethical, high-quality care and reproductive autonomy.

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.

Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population

OBJECTIVE

To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type.

STUDY DESIGN

We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status.

RESULTS

Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI.

CONCLUSIONS

In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth.

IMPLICATIONS

Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.

Changes in Rates of Inpatient Postpartum Long-Acting Reversible Contraception and Sterilization in the USA, 2012-2016

OBJECTIVES

To examine recent rates of long-acting and permanent methods (LAPM) of contraception use during delivery hospitalization and correlates of their use.

METHODS

A retrospective cohort study utilizing the 2012-2016 National Inpatient Sample of hospitalizations in the United States of America. The International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes were used to identify deliveries, inpatient long-acting reversible contraception (IPP LARC), and postpartum tubal ligation (PPTL). We conducted univariable and multivariable logistic regression to examine associations between demographic, clinical, hospital and geographical characteristics with likelihood of LAPM including IPP LARC and PPTL.

RESULTS

Our sample included 3,642,328 unweighted deliveries. The rate of IPP LARC increased from 34.6 to 54.9 per 10,000 deliveries (58.7%), while the rate of PPTL utilization decreased from 719.5 to 671.8 per 10,000 deliveries (6.6%) over the study period. In multivariable analysis of LAPM utilization versus neither, cesarean delivery (aOR 7.25, 95% CI 7.08-7.43) was associated with greater utilization. Native American (aOR 4.01, 95% CI 2.91-5.53) race was associated with increased use of IPP LARC compared to a non-long-acting method of contraception. Age between 18 and 29 years (aOR 6.21, 95% CI 5.42-7.11) was associated with greater use of IPP LARC versus PPTL. Delivering in a rural hospital ((aOR 0.09, 95% CI 0.06-0.12) and cesarean delivery (aOR 0.09, 95% CI 0.06-0.12) were associated with greater use PPTL versus IPP LARC.

CONCLUSIONS

The IPP LARC rate remains at less than 10% the PPTL rates in our study timeframe. The demonstrated variation in uptake of highly effective methods of contraception inpatient after delivery offer possible opportunities for better understanding and improvement in access.

Cost sharing, postpartum contraceptive use, and short interpregnancy interval rates among commercially insured women

BACKGROUND

Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period.

OBJECTIVE

This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery.

STUDY DESIGN

We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing, >$0-<$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type.

RESULTS

Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P<.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P<.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point.

CONCLUSION

Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.

The age of LARC: making sexual citizens on the frontiers of technoscientific healthism

Routinely positioned as the 'first-line option' for contraceptive choice-making, long-acting reversible contraception (LARC) promotion efforts have come under critical scrutiny by reproductive justice advocates for the extent to which public health actors' preference for LARC devices may override potential users' ability to freely (not) choose to use contraception among an array of options. We identify LARC promotion discourse as constituting 'The Age of LARC': multifarious strategies for producing responsible sexual citizens whose health behaviours are empowered via a LARC-only approach to contraceptive use. We suggest that immediate postpartum LARC insertion policies, which have proliferated in the U.S. since 2012, exemplify the new era of LARC hegemony, in which urgency, efficiency, cost-effectiveness, and outcomes dominate both health policy and clinical practice around these contraceptive technologies. By following these efforts to facilitate access to and use of immediate postpartum LARC, we find a discourse on sexual citizenship that paradoxically constructs sexual health freedom through the use of a single class of contraceptive technologies.

Initiation of Postpartum Contraception by 90 Days at a Midwest Academic Center

INTRODUCTION

Contraception is a critical component of addressing the health needs of women in the postpartum period. We assessed contraception initiation by 90 days postpartum at a large, academic medical center in the Midwest.

METHODS

In this retrospective cohort study, 299 charts were randomly sampled and 231 were analyzed from deliveries between May 1 to July 5, 2018. Contraceptive method, maternal demographics, and obstetric characteristics at hospital discharge were collected, as well as contraceptive method at the postpartum follow-up appointment. Methods and strata of contraception were categorized as follows: 1) highly effective methods (HEM) defined as sterilization, intrauterine device, or implant, 2) moderately effective methods (MEM) defined as injectable contraception, progestin-only pills, and combined estrogen/progestin pills, patches, and rings, and 3) less effective methods (LEM) defined as condoms, natural family planning, and lactational amenorrhea. Women lost to follow-up who had initiated a HEM or injectable contraception were coded as still using the method at 90 days. We used logistic regression to identity factors associated with HEM use.

RESULTS

Of the 231 included patients, 118 (51%) received contraception before hospital discharge and 166 (83%) by 90 days postpartum. Postpartum visits were attended by 74% (171/231) of patients. Before hospital discharge, 28% (65/231) obtained a HEM and 41% (82/200) were using a HEM by 90 days postpartum. Patients obtaining HEM or injectable contraception before hospital discharge attended a follow-up visit less often than those who did not receive HEM before discharge (RR = 0.68, 95% CI: 0.54 - 0.86, p ≤ 0.01).

CONCLUSION

When readily available, many women will initiate contraception in the postpartum period. Health systems should work to ensure comprehensive access to contraception for women in the postpartum period.

Variation in effectiveness of planned postpartum contraception at two time points from prenatal to postpartum care

OBJECTIVE

To identify characteristics of women who have consistent plans in terms of contraceptive effectiveness from antepartum to postpartum care.

STUDY DESIGN

This is a secondary analysis of a retrospective chart review of women who delivered at a single tertiary care center from 2012 to 2014. Preferred postpartum contraceptive plan was abstracted at three time points (prenatal care, hospital discharge, and outpatient postpartum care) and categorized into three tiers of effectiveness. We then examined consistency between the first two time points for the effectiveness in postpartum contraceptive method planned.

RESULTS

Of the 8,394 women in the study cohort, 2,642 (31.5%) had a consistent postpartum contraceptive plan. Women who had a consistent plan were more likely to have higher parity (aOR 2.36, 95% CI 2.06-2.70 for parity 2+), choose highly effective methods of contraception (p < 0.001), achieve their contraception plan (adjusted odds ratio [aOR] 2.16, 95% confidence interval [95% CI] 1.85-2.52), but not more likely to have a subsequent pregnancy within 365 days of delivery (aOR 0.92, 95% CI 0.81-1.05).

CONCLUSION

Better understanding contraceptive decision-making as a journey and removing external barriers during that process is a necessary component of pregnancy care.

IMPLICATIONS

Counseling and documentation of contraceptive preferences throughout antepartum and postpartum care can help improve contraceptive outcomes.

The Association of Public Insurance with Postpartum Contraception Preference and Provision

BACKGROUND

Prior studies have noted that public insurance status is associated with increased uptake of postpartum contraception whereas others have pointed to public insurance as a barrier to accessing highly effective forms of contraception.

OBJECTIVE

To assess differences in planned method and provision of postpartum contraception according to insurance type.

STUDY DESIGN

This is a secondary analysis of a retrospective cohort study examining postpartum women delivered at a single hospital in Cleveland, Ohio from 2012-2014. Contraceptive methods were analyzed according to Tier-based effectiveness as defined by the Centers for Disease Control and Prevention. The primary outcome was postpartum contraception method preference. Additional outcomes included method provision, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery.

RESULTS

Of the 8281 patients in the study cohort, 1372 (16.6%) were privately and 6990 (83.4%) were publicly insured. After adjusting for the potentially confounding clinical and demographic factors through propensity score analysis, public insurance was not associated with preference for a Tier 1 versus Tier 2 postpartum contraceptive method (matched adjusted odds ratio [maOR] 0.89, 95% CI 0.69-1.15), but was associated with a preference for Tier 1/2 vs Tier 3/None (maOR 1.41, 95% CI 1.17-1.69). There was no difference between women with private or public insurance in terms of method provision by 90 days after delivery (maOR 0.94, 95% CI 0.75-1.17). Public insurance status was also associated with decreased postpartum visit attendance (maOR 0.54, 95% CI 0.43-0.68) and increased rates of subsequent pregnancy within 365 days of delivery (maOR 1.29, 95% CI 1.05-1.59).

CONCLUSION

Public insurance status does not serve as a barrier to either the preference or provision of effective postpartum contraception. Women desiring highly- or moderately effective methods of contraception should have these methods provided prior to hospital discharge to minimize barriers to method provision.

Cost Sharing and Utilization of Postpartum Intrauterine Devices and Contraceptive Implants Among Commercially Insured Women

BACKGROUND

Cost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women.

METHODS

Using the Clinformatics Data Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4-60 days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device + placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60 days postpartum (yes/no).

RESULTS

We identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60 days postpartum was observed after 5.2% (n = 20,604) of deliveries. Inpatient LARC insertion (n = 233; 0.06% of deliveries) was less common than outpatient LARC insertion (n = 20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93-5,055.91; inpatient implant: median, $11.91; range, $2.49-650.14; outpatient IUD: median, $25.00; range, $0.01-3,354.80; outpatient implant: median, $27.20; range, $0.18-2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60 days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71-0.77).

CONCLUSIONS

Cost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.

Family planning service provision in Illinois religious hospitals: Racial/ethnic variation in access to non-religious hospitals for publicly insured women

OBJECTIVES

To identify religious affiliations of hospitals and access to family planning (FP) care available to publicly insured women in Cook County, Illinois.

DESIGN

We analyzed Illinois public insurance enrollment data and family planning service claims (2015-2018) for women 18-45.

RESULTS

Eighty-five percent of Black/Hispanic women were enrolled in Medicaid managed care plans with a higher percentage of Catholic healthcare than Cook County as a whole compared to 75% of White women (p<0.0001). There were fewer FP services at Catholic (IRR 0.072, 95% CI 0.068-0.076) and Christian non-Catholic (IRR 0.55, 95% CI 0.53-0.56) compared to non-religious hospitals.

CONCLUSIONS

Medicaid managed care plans may restrict family planning care by limiting patients to religious hospitals.