Six- and twelve-month documented removal rates among women electing postpartum inpatient compared to delayed or interval contraceptive implant insertions after Medicaid payment reform

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.

The Etonogestrel Implant in Adolescents: Factors Associated With Removal for Bothersome Bleeding in the First Year After Insertion

STUDY OBJECTIVE

Temporizing measures such as hormonal pills can temporarily improve the side effect of breakthrough bleeding in individuals using the etonogestrel implant. The aims of this study were to determine demographic factors that are associated with bothersome bleeding and to evaluate the impact of prescribing temporizing measures on implant continuation.

DESIGN

Retrospective chart review.

SETTING

The research was conducted in an adolescent medicine primary and specialty care clinic, an adolescent family planning clinic, and a clinic that cares for parenting adolescents.

PARTICIPANTS

A chart review was conducted on 1200 patients aged 12-24 years who received the implant in 2016.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The primary outcome measure was removal of the implant within the first year of use. We followed each patient for 1 year to determine rates of removal, reasons for removal, and temporizing measures prescribed for bleeding.

RESULTS

Younger age and lower body mass index were associated with reporting bothersome vaginal bleeding. Patients who were nulliparous or had bothersome bleeding were more likely to have the implant removed in the first year. Patients who received a temporizing measure for bleeding were more likely to retain the implant for 1 year than were those who did not receive one (67.1% vs 40%, P < .001).

CONCLUSIONS

Some patients are more likely to report concerns with bleeding or to have the implant removed in the first year after insertion. Prescribing temporizing measures to control bothersome vaginal bleeding may decrease rates of removal in the first year.

Timing of postpartum etonogestrel-releasing implant insertion and bleeding patterns, weight change, 12-month continuation and satisfaction rates: a randomized controlled trial

OBJECTIVES

To evaluate whether timing of etonogestrel (ENG) implant insertion during the postpartum period affects maternal bleeding patterns, body mass index (BMI) and 12-month satisfaction and continuation rates.

STUDY DESIGN

This is a secondary analysis of an open, randomized, controlled trial. Postpartum women were block-randomized to early (up to 48 h postpartum) or delayed (6 weeks postpartum) insertion of an ENG implant. Bleeding patterns and BMI were evaluated every 90 days for 12 months. At 12 months, we measured implant continuation rates and used Likert and face scales to measure users' satisfaction. The level of significance was 0.4% (adjusted by Bonferroni test for multiplicity).

RESULTS

We enrolled 100 postpartum women; we randomized 50 to early and 50 to delayed postpartum ENG implant insertion. Bleeding patterns were similar between groups. Amenorrhea rates were high in both groups during the follow-up (52%-56% and 46%-62% in the early and delayed insertion group, respectively). Prolonged bleeding episodes were unusual in both groups during the follow-up (0-2%). Maternal BMI was similar between groups and decreased over time. Twelve-month continuation rates were similar between groups (early insertion: 98% vs. delayed insertion: 100%, p=.99). Most participants were either very satisfied or satisfied with the ENG implant in both groups (p=.9).

CONCLUSION

Women who underwent immediate postpartum insertion of the ENG implant have similar bleeding patterns, BMI changes, and 12-month satisfaction and continuation rates compared to those who underwent delayed insertion.

IMPLICATIONS

Our results from a secondary analysis of a clinical trial support that satisfaction, continuation and bleeding patterns do not differ when women received contraceptive implants immediately postpartum or at 6 weeks. However, the emphasis on infant growth in the trial and easy access to delayed placement may have influenced results.

Effect of cost on early removal of contraceptive implants: a prospective cohort study

OBJECTIVES

To evaluate the effect of the cost of subdermal etonogestrel implant (SEI) on the continuation rate one year after insertion, and to assess the reasons given by users to remove the implant before the expiration date.

METHODS

Prospective cohort study conducted among 265 women who chose the SEI as a contraceptive method in a sexual and reproductive health center in the eastern region of Spain, between October/2012 and October/2017. The sample was divided into two cohorts depending on the cost of the implant for the user (free-of-charge or requiring partial payment). Kaplan-Meier survival curves were used to compare the cumulative removal rates of free implants with partially paid implants within the first year of insertion. Cox proportional hazards models were used to control for confounders.

RESULTS

After adjusting for confounders, no significant associations were found between the cost of the implant and its removal within a year of insertion. No significant associations were found in the reasons given for implant removal and for the duration of implant use.

CONCLUSIONS

Cost was not associated with SEI continuation rates within the first year of use. No other significant variables were found to explain implant removal within one year of use.

Women's informed choice and satisfaction with immediate postpartum long-acting reversible contraception in Georgia

Background

Several state Medicaid agencies have recently started reimbursing for long-acting reversible contraception (LARC) placement immediately postpartum. Women's perspectives are critical for ensuring that this change increases access to LARC while empowering women to choose the method and timing of contraception that best meets their needs. We conducted a pilot study in Georgia, which recently changed its Medicaid reimbursement policy, to assess women's informed choice and satisfaction with immediate postpartum LARC.

Methods

We sampled all women with a live birth paid for by Georgia Medicaid during November 2015 through February 2017 who received an immediate postpartum LARC. We then used a one-to-one match to sample women who did not receive immediate postpartum LARC. Women were contacted via telephone for a 25-30 min interview regarding their knowledge, attitudes, and behaviors related to immediate postpartum LARC and their satisfaction with postpartum contraception. We calculated descriptive statistics and components of informed choice overall and by receipt of immediate postpartum LARC, using chi-square tests to calculate differences by group.

Results

We approached 470 women and completed interviews with 51; 25 (49%) received immediate postpartum LARC (24 implants, 1 intrauterine device). Two-thirds reported their provider discussed the option of receiving immediate postpartum LARC during prenatal care, with over 90% reporting they received all the information they needed to make a decision. Most women believed the ideal time to begin using birth control postpartum is in the hospital immediately after delivery, although this differed significantly by women's receipt of immediate postpartum LARC. Most women who received immediate postpartum LARC reported they are very or extremely happy with their device, although 40% also reported wanting their device removed at some point.

Conclusions

Women on Medicaid in Georgia report making informed choices regarding immediate postpartum LARC. Among those who received immediate postpartum LARC, women report high levels of satisfaction.

Disparities in Postpartum Contraceptive Counseling and Provision Among Mothers of Preterm Infants

OBJECTIVE

Use of effective contraception could be one method to decrease recurrent preterm birth by increasing intervals between pregnancies. We assessed correlates of contraceptive counseling and uptake among women who delivered preterm.

MATERIALS AND METHODS

This is a retrospective cohort study of women who delivered live-born singletons or twins before 32 weeks' gestation. We assessed documented contraceptive counseling and method uptake by postpartum discharge, using inpatient medical records, and correlates of highly effective contraception uptake by the postpartum visit using outpatient records.

RESULTS

Of 594 eligible women, 44.6% (n = 265) had documented inpatient contraceptive counseling, but only 21.4% (n = 127) left the hospital using a World Health Organization (WHO) tier 1 or 2 method. Women who were younger, non-Hispanic black, multiparous, and delivered at earlier gestational ages were more likely to have inpatient counseling documented. Compared with women with private insurance, women with public insurance were more likely to have documented counseling (22.8% vs. 87.5%, p < 0.001; adjusted odds ratio [aOR] 9.55, 95% confidence interval [CI] 5.31-17.2) and to uptake a WHO tier 1 or 2 method as an inpatient (5.8% vs. 52.0%, p < 0.001; aOR 9.51, 95% CI 4.78-18.9). Of the 175 women with outpatient records available who attended a postpartum visit, only 54.9% (n = 96) adopted a WHO tier 1 or tier 2 method.

CONCLUSION

Although all women in this cohort were at risk of recurrent preterm birth, counseling about contraception after a preterm birth (<32 weeks) was not universal. Women with multiple risk factors for recurrent preterm birth, such as multiparity and public insurance, were more likely to have received documented contraceptive counseling and highly effective contraceptives.

The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels

Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives.