Policy change is not enough: engaging provider champions on immediate postpartum contraception

Postpartum long-acting reversible contraceptive adoption after a statewide initiative

OBJECTIVES

To examine the effects of a comprehensive, multiyear (2015-2020) statewide contraceptive access intervention in Delaware on the contraceptive initiation of postpartum Medicaid patients. The program aimed to increase access to all contraceptives, including long-acting reversible contraceptives (LARC). The program included interventions specifically targeting postpartum patients (Medicaid payment reform and hospital-based immediate postpartum (IPP) LARC training) and interventions in outpatient settings (provider training and operational supports).

DATA SOURCES AND STUDY SETTING

We used Medicaid claims data between 2012 and 2019, from Delaware and Maryland (a comparison state), to identify births and postpartum contraceptive methods up to 60 days postpartum among patients aged 15-44 years who were covered in a full-benefit eligibility category.

STUDY DESIGN

Using difference-in-differences, we assessed changes in LARC, tubal ligation, and short-acting methods (oral contraceptive, injectable, patch/ring). LARC rates were assessed at 60 days after delivery and on an immediate postpartum basis. Other methods were only assessed at 60 days. Analyses were conducted separately for an early-adopting high-capacity hospital (that delivers approximately half of all Medicaid financed births) and for all other later-adopting hospitals in the state.

DATA COLLECTION/EXTRACTION METHODS

Data were extracted from administrative claims.

PRINCIPAL FINDINGS

The program increased postpartum LARC insertions by 60 days after delivery by 11.7 percentage points (95% CI: 10.7, 12.8) in the early-adopting hospital and 6.9 percentage points (95% CI: 4.8, 5.9) in later-adopting hospitals. Increases in IPP versus outpatient LARC drove the change, but we did not find evidence that IPP crowded-out outpatient LARC services. We observed decreases in short-acting methods, suggesting substitution between methods, but the share of patients with any method increased at the early-adopting hospital (5.2 percentage points; 95% CI: 3.5, 6.9) and was not statistically significantly different at the later-adopting hospitals.

CONCLUSIONS

Direct reimbursement for IPP LARC, in combination with provider training, had a meaningful impact on the share of Medicaid-enrolled postpartum women with LARC claims.

Examining the impact of Medicaid payments for immediate postpartum long-acting reversible contraception on the mental health of low-income mothers

OBJECTIVE

To examine the effect of Medicaid immediate postpartum long-acting reversible contraception (IPP LARC) reforms on self-reported mental health among low-income mothers aged 18-44 years.

DATA SOURCES AND STUDY SETTING

We used national secondary data on self-reported mental health status in the past 30 days from the core component (2014-2019) of the Behavioral Risk Factor Surveillance System (BRFSS).

STUDY DESIGN

We estimated linear probability models for reporting any days of not good mental health in the past 30 days. We adjusted for individual-level factors, state-level factors, and state and year fixed effects. Our primary independent variable was an indicator for IPP LARC payment reform. We examined the effect of the Medicaid payment reforms on self-reported mental health status in the past 30 days using difference-in-differences and event-study designs.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

State adoption of Medicaid IPP LARC reforms was associated with significant reductions (between 5.7% and 11.5%) in the predicted probability of reporting any days of not good mental health among low-income mothers. Treatment effects appeared to be driven by respondents reporting two or more children (less than 18 years of age) in the household (ATT = -0.028, p = 0.04). Results are robust to a series of sensitivity tests and alternative estimation strategies.

CONCLUSIONS

Our findings suggest that contemporary efforts to improve access to contraceptive methods may have important benefits beyond reproductive autonomy. These findings have implications for policymakers as the landscape related to family planning services continues to shift.

Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018

Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

Strategies for obstetricians and gynecologists to advance reproductive autonomy in a post-Roe landscape

The monumental reversal of Roe vs Wade dramatically impacted the landscape of reproductive healthcare access in the United States. The decision most significantly affects communities that historically have been and continue to be marginalized by systemic racism, classism, and ableism within the medical system. To minimize the harm of restrictive policies that have proliferated since the Supreme Court overturned Roe, it is incumbent on obstetrician-gynecologists to modify practice patterns to meet the pressing reproductive health needs of their patients and communities. Change will require cross-discipline advocacy focused on advancing equity and supporting the framework of reproductive justice. Now, more than ever, obstetrician-gynecologists have a critical responsibility to implement new approaches to service delivery and education that will expand access to evidence-based, respectful, and person-centered family planning and early pregnancy care regardless of their practice location or subspecialty.

Increasing Access to Contraception: Examining Barriers and Facilitators of Long-Acting Reversible Contraception

Objective(s): To identify barriers and facilitators related to reimbursement processes, device acquisition costs, stocking, and supply of long-acting reversible contraception (LARC) from 27 jurisdictions (26 states/1 territory) participating in the Increasing Access to Contraception Learning Community from 2016 to 2018. Materials and Methods: A descriptive study using qualitative data collected through 27 semistructured key informant interviews was conducted during the final year of the learning community among all jurisdictional teams. Excerpts were extracted and coded by theme, then summarized as barriers or facilitators using implementation science methods. Results: Most jurisdictions (89%) identified barriers to reimbursement processes, device acquisition, stocking, and supply of LARC devices, and 85% of jurisdictions identified facilitators for these domains. Payment methodology challenges and lack of billing and coding processes were identified as the most common barriers to reimbursement processes. Device acquisition cost challenges and lack of delivery facility protocols for billing were the most common barriers to device acquisition, stocking, and supply of LARC. The most common facilitator of reimbursement processes was expanded payment methodology options, whereas supplemental funding for acquisition costs and protocol development were identified as the most common facilitators of device acquisition, stocking, and supply. Conclusion: Revised payment methodologies and broader health systems changes including additional funding sources and protocols for billing, stocking, and supply were used by learning community jurisdictions to address identified barriers. The learning community framework offers a forum for information exchange, peer-to-peer learning, and sharing of best practices to support jurisdictions in addressing identified barriers and facilitators affecting contraception access.

Mapping Long-acting Reversible Contraceptive Interventions to the Social Ecological Model: A Scoping Review

INTRODUCTION

Long-acting reversible contraception (LARC) is one option for preventing unintended pregnancies and short interpregnancy intervals. Efforts to increase access to contraception may benefit from applying the social ecological model (SEM), a framework that considers individual, interpersonal, organizational, community, and policy influences on behavior. We aimed to summarize findings from interventions on LARC use and map interventions to SEM levels.

METHODS

We conducted a scoping review of the 2010-2020 literature in PubMed/MEDLINE and Embase databases to summarize interventions that did and did not increase LARC use. Although increasing LARC use is not an appropriate goal from a reproductive autonomy standpoint, it is the stated goal of much of the research conducted to date and typically indicates an improvement in access. We mapped these interventions to SEM levels and categorized their strategies: cost support, patient counseling, administrative support, provider training, and other.

RESULTS

Of 27 interventions reviewed, 17 (63%) increased LARC use. We observed a greater proportion of interventions that increased LARC uptake among those with strategies implemented at policy (8/10 [80%]) or organizational (14/19 [74%]) SEM levels compared with interventions implemented at other SEM levels. When both individual and organizational SEM-level components were implemented, five of six interventions (83%) increased uptake. All five interventions with both organizational- and policy-level components increased LARC use. Among the 27 interventions, patient counseling (n = 12) and cost support (n = 12) were common strategies. Five of 12 interventions (42%) involving patient counseling and 11 of 12 (92%) involving cost support increased LARC use.

CONCLUSIONS

Organizational and policy SEM components and cost support strategies were most prevalent in interventions that increased LARC use. Future interventions to improve access to contraception, while respecting patient autonomy, could incorporate more than one SEM level.

A socioecological perspective to contraceptive access for women experiencing homelessness in the United States

OBJECTIVE

Although persons who are pregnancy-capable and experiencing homelessness may have a strong desire to avoid pregnancy, they face unique barriers to contraception. This multimethod qualitative study aimed to identify preferences for, barriers to, and facilitators of contraceptive access and use among women experiencing homelessness in the United States using a systems perspective.

STUDY DESIGN

We conducted semistructured interviews with women experiencing homelessness (n = 19), healthcare providers (n = 6), and social service providers (n = 6). We recruited participants from community-based, housing, and medical organizations in North Texas in the United States. Two coders conducted thematic analysis and reached consensus for codes.

RESULTS

Women participants were in emergency shelter, unsheltered, or transitional/rapid rehousing. We stratified themes using the Socioecological Framework to illustrate factors affecting contraception access at individual, interpersonal, organizational and community, and societal levels. Notable results include women's preferences for long-acting reversible contraception, difficulties healthcare providers face in initiating contraceptive counseling, and the underutilized role of social service providers in reproductive healthcare. Insurance policies, connections between health clinics and community organizations, and organizational priorities both facilitated and hindered women experiencing homelessness's access to women's healthcare services.

CONCLUSION

This study identified opportunities throughout the healthcare and social service systems to support contraceptive access for women experiencing homelessness. Future interventions should strengthen and leverage these connections to promote access among this vulnerable population with the goal of supporting reproductive autonomy.

IMPLICATIONS

This study explored the reproductive health needs of women experiencing homelessness. Multilevel interventions, such as interdisciplinary care, patient-centered approaches, and an emphasis on health literacy, are needed to adequately provide the preferred methods of contraception for women experiencing homelessness, thus enabling reproductive autonomy for this population.

Health Insurance Coverage and Postpartum Outcomes in the US: A Systematic Review

Importance

Approximately half of postpartum individuals in the US do not receive any routine postpartum health care. Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care.

Objective

To assess whether health insurance coverage extension or improvements in access to health care are associated with postpartum health care utilization and maternal outcomes within 1 year post partum.

Evidence Review

Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov were searched for US-based studies from inception to November 16, 2022. The reference lists of relevant systematic reviews were scanned for potentially eligible studies. Risk of bias was assessed using questions from the Cochrane Risk of Bias tool and the Risk of Bias in Nonrandomized Studies of Interventions tool. Strength of evidence (SoE) was assessed using the Agency for Healthcare Research and Quality Methods Guide.

Findings

A total of 25 973 citations were screened and 28 mostly moderate-risk-of-bias nonrandomized studies were included (3 423 781 participants) that addressed insurance type (4 studies), policy changes that made insurance more comprehensive (13 studies), policy changes that made insurance less comprehensive (2 studies), and Medicaid expansion (9 studies). Findings with moderate SoE suggested that more comprehensive association was likely associated with greater attendance at postpartum visits. Findings with low SoE indicated a possible association between more comprehensive insurance and fewer preventable readmissions and emergency department visits.

Conclusions and Relevance

The findings of this systematic review suggest that evidence evaluating insurance coverage and postpartum visit attendance and unplanned care utilization is, at best, of moderate SoE. Future research should evaluate clinical outcomes associated with more comprehensive insurance coverage.

Medicaid Payment For Postpartum Long-Acting Reversible Contraception Prompts More Equitable Use

To increase access to highly effective contraception and improve reproductive autonomy, a growing number of state Medicaid programs pay for the provision of immediate postpartum long-acting reversible contraception (LARC) in addition to providing a global payment for maternity care. Using Pregnancy Risk Assessment Monitoring System data, we examined postpartum LARC use both overall and by race and ethnicity among respondents with Medicaid-paid births during the period 2012-18 in eight states that implemented immediate postpartum LARC payment and eight states without it. Using a quasi-experimental difference-in-differences design, we found that the policy resulted in an overall 2.1-percentage-point increase in postpartum LARC use. Our triple-differences analysis found no significant change among White mothers and a 3.7-percentage-point increase in use among Black mothers compared with White mothers. Additional research is needed to determine whether this increase was aligned with patients' preferences and whether hospitals' immediate postpartum LARC policies and practices take a patient-centered approach that supports reproductive autonomy and equity.

Trends in Postpartum Contraceptive Use in 20 U.S. States and Jurisdictions: The Pregnancy Risk Assessment Monitoring System, 2015-2018

INTRODUCTION

In the last decade, state and national programs and policies aimed to increase access to postpartum contraception; however, recent data on population-based estimates of postpartum contraception is limited.

METHODS

Using Pregnancy Risk Assessment Monitoring System data from 20 sites, we conducted multivariable-adjusted weighted multinomial regression to assess variation in method use by insurance status and geographic setting (urban/rural) among people with a recent live birth in 2018. We analyzed trends in contraceptive method use from 2015 to 2018 overall and within subgroups using weighted multinomial logistic regression.

RESULTS

In 2018, those without insurance had lower odds of using permanent methods (adjusted odds ratio [AOR], 0.72; 95% confidence interval [CI], 0.53-0.98), long-acting reversible contraception (LARC) (AOR, 0.67; 95% CI, 0.51-0.89), and short-acting reversible contraception (SARC) (AOR, 0.61; 95% CI, 0.47-0.81) than those with private insurance. There were no significant differences in these method categories between public and private insurance. Rural respondents had greater odds than urban respondents of using all method categories: permanent (AOR, 2.15; 95% CI, 1.67-2.77), LARC (AOR, 1.31; 95% CI, 1.04-1.65), SARC (AOR, 1.42; 95% CI, 1.15-1.76), and less effective methods (AOR, 1.38; 95% CI, 1.11-1.72). From 2015 to 2018, there was an increase in LARC use (odds ratio [OR], 1.03; 95% CI, 1.01-1.05) and use of no method (OR, 1.05; 95% CI, 1.02-1.07) and a decrease in SARC use (OR, 0.97; 95% CI, 0.95-0.99). LARC use increased among those with private insurance (OR, 1.05; 95% CI, 1.02-1.08) and in urban settings (OR, 1.04; 95% CI, 1.02-1.07), but not in other subgroups.

CONCLUSIONS

We found that those without insurance had lower odds of using effective contraception and that LARC use increased among those who had private insurance and lived in urban areas. Strategies to increase access to contraception, including increasing insurance coverage and investigating whether effectiveness of existing initiatives varies by geographic setting, may increase postpartum contraceptive use and address these differences.

Increasing access to immediate postpartum contraceptive implants: a prospective clinical trial among patients with opioid use disorder

OBJECTIVE

To evaluate the effects of increased access to immediate postpartum contraceptive implants (IPI) on repeat pregnancy and contraceptive use rates among patients with opioid use disorder (OUD).

MATERIALS AND METHODS

Between 2016 and 2018, 194 postpartum patients with OUD were offered the option of IPI placement at an institution with limited immediate postpartum long-acting reversible contraception availability and followed for one-year postpartum. Differences in pregnancy rates between participants who did and did not choose IPI were examined using logistic regression with inverse probability of treatment weighting from propensity scores accounting for differences between the two groups.

RESULTS

Among 194 participants, 96 (49.5%) chose an IPI and 98 (50.5%) chose an alternative method or no contraception (non-IPI). Among IPI participants, 76 (80.9%) continued to use their implant at one-year postpartum. Overall, 19 participants had a repeat pregnancy and 11 (57.9%) were unintended. In multivariable analyses, repeat pregnancy was more likely among those who did not choose IPI (OR 9.90; 95% CI 3.58-27.03) than those who did. Participants with OUD and who used alcohol (11.66; 1.38, 98.20) or cocaine (2.72; 1.23, 5.99) during pregnancy were more likely to choose IPI. Participants who were married (0.28; 0.09, 0.89), engaged in OUD treatment prior to pregnancy (0.48; 0.25, 0.93), and happier when they found out about their pregnancy (0.87; 0.77, 0.98) were less likely to choose IPI.

CONCLUSION

Offering patients with OUD the option of IPI is associated with high utilisation and continuation rates, and low rates of repeat pregnancy within one-year postpartum.

Improving Access to and Quality of Postpartum Contraception Provision

Sexual activity and fertility can resume shortly after childbirth, but there are barriers to contraceptive access in the postpartum period. Unintended pregnancy and short interpregnancy intervals (of less than one year) can increase the risk of obstetric and neonatal complications. The antenatal period presents an opportunity to discuss contraceptive options, many of which can be safely initiated immediately after childbirth. Successful delivery of a postpartum contraception program requires an adequate number of maternity staff trained to provide the full range of methods.

Immediate Postpartum Long-Acting Reversible Contraceptive Use Following State-Specific Changes in Hospital Medicaid Reimbursement

Importance

Facilitating access to the full range of contraceptive options is a health policy goal; however, inpatient provision of postpartum long-acting reversible contraceptive (LARC) methods has been limited due to lack of hospital reimbursement. Between March 2014 and January 2015, the Medicaid programs in 5 states began to reimburse hospitals for immediate postpartum LARC separately from the global maternity payment.

Objective

To examine the association between Medicaid policies and provision of immediate postpartum LARC, and to examine hospital characteristics associated with policy adoption.

Design, Setting, and Participants

This cross-sectional study used interrupted time series analysis. The setting was population-based in Georgia, Iowa, Maryland, New York, and Rhode Island. Participants included individuals who gave birth in these states between 2011 and 2017 (n = 3 097 188). Statistical analysis was performed from June 2021 to August 2022.

Exposures

Childbirth after the start of Medicaid's reimbursement policy.

Main Outcomes and Measures

Immediate postpartum LARC (outcome), teaching hospital, Catholic-owned or operated, obstetrical care level, and urban or rural location (hospital characteristics).

Results

The study included a total of 1 521 491 births paid for by Medicaid and 1 575 697 paid for by a commercial payer between 2011 and 2017. Prior to Medicaid reimbursement changes, 489 389 of 726 805 births (67%) were to individuals between 18 and 29 years of age, 219 363 of 715 905 births (31%) were to non-Hispanic Black individuals, 227 639 of 715 905 births (32%) were to non-Hispanic White individuals, 155 298 of 715 905 births (22%) were to Hispanic individuals, and 113 605 of 715 905 births (16%) were to individuals from other non-Hispanic racial groups. Among Medicaid-paid births, the policies were associated with an increase in the rate of immediate postpartum LARC provision in all states, although results for Maryland were not consistent across sensitivity analyses. The change in trend ranged from a quarterly increase of 0.05 percentage points in Maryland (95% CI, 0.01-0.08 percentage points) and 0.05 percentage points in Iowa (95% CI, 0.00-0.11 percentage points) to 0.82 percentage points (95% CI, 0.73-0.91 percentage points) in Rhode Island. The policy was also associated with an increase in immediate postpartum LARC provision among commercially paid births in 4 of 5 states. After the policy, only 38 of 366 hospitals (10%) provided more than 1% of birthing people with immediate postpartum LARC. These adopting hospitals were less likely to be Catholic (0% [0 of 31] vs 17% [41 of 245]), less likely to be rural (10% [3 of 31] vs 33% [81 of 247]), more likely to have the highest level of obstetric care (71% [22 of 31] vs 29% [65 of 223]) and be teaching hospitals (87% [27 of 31] vs 43% [106 of 246]) compared with nonadopting hospitals.

Conclusions and Relevance

This cross-sectional study's findings suggest that Medicaid policies that reimburse immediate postpartum LARC may increase access to this service; however, policy implementation has been uneven, resulting in unequal access.

An Initiative "that you do for one person": Identifying Barriers and Facilitators to Implementing an Immediate Postpartum LARC Initiative in Florida Hospitals

INTRODUCTION

In the United States (U.S.), perinatal quality improvement collaboratives have pursued implementing immediate postpartum long-acting reversible contraception (LARC) initiatives to increase people's access to contraception and support their fertility desires. This process evaluation aimed to identify barriers and facilitators to implementing an immediate postpartum LARC initiative in Florida.

METHODS

Data collection included in-depth qualitative assessments (i.e., interviews, small focus group discussions) with hospitals in pre- and early stages of the implementation process. Snowball sampling was used to recruit participants. Interviews were conducted in-person or via Zoom or phone and were audio-recorded and transcribed verbatim. Four of the five domains within the Consolidated Framework for Implementation Research (e.g., process, intervention characteristics, inner and outer settings) informed the study design and data collection/analysis.

RESULTS

Fourteen staff of diverse job roles from five hospitals participated. Factors that facilitated implementation were the strength of the evidence, relative advantage, internal and external networks, and engaging staff. Barriers to implementation included billing and reimbursement and needing significant support from external networks to progress through implementation phases.

DISCUSSION

Findings suggest that depending on the task or phase, multiple factors work in tandem to serve as implementation barriers and facilitators. Additionally, evaluating hospitals' progress at the pre- and early implementation phases was critical for quickly finding solutions and benefited other hospitals in different stages. As this initiative requires substantial support, health systems should create and sustain a culture of excellence and efficiency to facilitate implementing initiatives that improve care quality.

Review of Publicly Available State Policies for Long-Acting Reversible Contraception Device Reimbursement

Background: Provider challenges to accessing long-acting reversible contraception (LARC) include level of reimbursement for LARC device acquisition and cost to stock. State-level LARC device reimbursement policies that cover a greater proportion of the cost of the LARC device and enable providers to purchase LARC upfront may improve contraceptive access. Materials and Methods: To summarize state-level policies that include language on LARC device reimbursement in the outpatient setting, we conducted a systematic, web-based review among all 50 states of publicly available LARC device reimbursement policies that include coverage of LARC devices as a medical or pharmacy benefit, the use of the 340B Drug Pricing Program to purchase LARC devices, and separate payment for LARC devices outside of the Medicaid Prospective Payment System (PPS) payment rate for Federally Qualified Health Centers or Rural Health Clinics. Results: Forty-two percent (21/50) of states with publicly available state-level policies included language on LARC device reimbursement. Among the states, 24% (5/21) had coverage policies as a medical benefit, 33% (7/21) as a pharmacy benefit, and 19% (4/21) as both a medical benefit and pharmacy benefit; 38% (8/21) used the 340B Program to purchase LARC devices; and 62% (13/21) indicated separate payment for LARC devices outside of the Medicaid PPS payment rate. Conclusion: State-level policies for LARC device reimbursement vary, highlighting differences in reimbursement strategies across the U.S. Future research could explore how the implementation of these payment methods may impact LARC device reimbursement and whether increased reimbursement may improve access to the full range of contraceptive methods.

Barriers and Facilitators to Implementing Immediate Postpartum Contraceptive Implant Programs: A Formative Implementation Research

Objective

This study sought to identify the factors that act as barriers and facilitators to developing and implementing Immediate postpartum (IPP) insertion of contraceptive implants service according to the Consolidated Framework for Implementation Research (CFIR).

Methods

We conducted in-depth interviews and focus group discussions to explore IPP contraceptive implantation programs implemented in community, regional, and university hospitals in Thailand. The CFIR was used to guide the data collection and analyses.

Results

All CFIR domains were found to have an impact on planning and implementation. Out of 38 constructs, nine were identified as either barriers or facilitators, and four were determined to be both. Barriers included an insufficient training budget, lack of policy to support non-teenagers, disconnect among organizations, and lack of knowledge on the part of the clients. Facilitators included the relative advantage of implants over other contraceptive methods, reimbursement policy, laws that promote teenage autonomy, setting IPP implants as a key performance indicator (KPI), identifying project champions, and educating clients through antenatal counseling or multimedia intervention.

Conclusion

Barriers and facilitators to the successful implementation of an IPP contraceptive implant program were identified. In order to successfully implement this service, modifiable barriers should be overcome and facilitators should be strengthened. Strategies tailored to the local context should be developed to ensure the sustainability of the program. Educating clients is crucial and need both hospital- and community interventions.

Use of a Learning Community to Expand Access to Contraception

The Increasing Access to Contraception Learning Community was established to disseminate strategies and best practices to support 27 jurisdictions in the development of policies and programs to increase access to the full range of reversible contraceptives. We describe Learning Community activities and identify those that were most useful to participants. Although participation in Learning Community provided jurisdictional teams with structured activities such as virtual learning and peer networking opportunities, some teams struggled with full participation because of staffing turnover and shifts in priorities. (Am J Public Health. 2022;112(S5):S523-S527. https://doi.org/10.2105/AJPH.2022.306823).

Association of the Delaware Contraceptive Access Now Initiative with Postpartum LARC Use

Objectives

Although multi-component policy interventions can be important tools to increase access to contraception, we know little about how they may change contraceptive use among postpartum women. We estimate the association of the Delaware Contraceptive Access Now (DelCAN) initiative with use of postpartum Long-Acting Reversible Contraception (LARC). DelCAN included Medicaid payment reform for immediate postpartum LARC use, provider training and technical assistance in LARC provision, and a public awareness campaign.

Methods

We used a difference-in-differences design and data from the 2012 to 2017 pregnancy risk assessment monitoring system to compare changes in postpartum LARC use in Delaware versus 15 comparison states, and differences in such changes by women’s Medicaid enrollment.

Results

Relative to the comparison states, postpartum LARC use in Delaware increased by 5.26 percentage points (95% CI 2.90–7.61, P < 0.001) during the 2015–2017 DelCAN implementation period. This increase was the largest among Medicaid-covered women, and grew over the first three implementation years. By the third year of the DelCAN initiative (2017), the relative increase in postpartum LARC use for Medicaid women exceeded that for non-Medicaid women by 7.24 percentage points (95% CI 0.12–14.37, P = 0.046).

Conclusions for Practice

The DelCAN initiative was associated with increased LARC use among postpartum women in Delaware. During the first 3 years of the initiative, LARC use increased progressively and to a greater extent among Medicaid-enrolled women. Comprehensive initiatives that combine Medicaid payment reforms, provider training, free contraceptive services, and public awareness efforts may reduce unmet demand for highly effective contraceptives in the postpartum months.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-022-03433-2.

Perspectives of obstetricians and midwives on the provision of immediate postpartum intrauterine devices: a qualitative service evaluation

BACKGROUND

Immediate postpartum intrauterine device (PPIUD) insertion is safe and effective but largely unavailable in Europe. Data on maternity staff views on the provision and implementation of PPIUD services are limited. The objective of this qualitative evaluation was to explore the views and experiences of obstetricians and midwives providing PPIUD within a UK maternity setting, in order to identify areas for improvement and inform service provision in other areas.

METHODS

Qualitative health services research within two public maternity hospitals in Lothian (Edinburgh and surrounding region), UK. Interviews with 30 maternity staff (obstetricians n=8; midwives n=22) involved in PPIUD provision. Data were analysed thematically.

RESULTS

Maternity staff were positive about the benefits of PPIUD for women. Midwives reported initial concerns about PPIUD safety, and the impact on workload; these views shifted following training, and as PPIUD was embedded into practice. Having a large pool of PPIUD-trained staff was identified as an important factor in successful service implementation. Having PPIUD 'champions' was important to address staff concerns, encourage training uptake, and advocate for the service to ensure continued resourcing.

CONCLUSIONS

PPIUD in maternity services can help address unmet need for effective contraception in the immediate postpartum period. We emphasise the importance of widespread engagement around PPIUD among all healthcare professionals involved in the care of women, to ensure staff are informed and supported. Clinical champions and leaders play a key role in amplifying the benefits of PPIUD, and advancing organisational learning.

Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services

BACKGROUND

National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits-packages of resources and strategies to facilitate the implementation of new services-are a promising approach for guiding clinical practice change.

OBJECTIVE

This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing.

STUDY DESIGN

We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]).

RESULTS

In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were "extremely" or "somewhat" satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%-79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%-29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%-63%; hospitalization, 45%-58%; outpatient after delivery, 69%-65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care.

CONCLUSION

A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.

An exploratory survey regarding the Maryland Contraceptive Equity Act: clinician awareness and impact on contraception provision

Objective

The Maryland Contraceptive Equity Act took effect in January 2018 with the goal of reducing insurance barriers to contraception. We sought to assess the Act's impact on contraceptive provision.

Study Design

From March-August 2019, we emailed an exploratory survey to clinicians providing contraception in Maryland that queried awareness of the Act and changing practices.

Results

The survey had a 13% response rate (164/1256 clinicians). Fifty (31%) were aware of the Act. Clinicians rated the Act was somewhat likely to change prescribing practices (3.5/5 point Likert Scale, SD 1.3).

Conclusion

The majority of clinicians providing contraception in Maryland are not aware of the Act. If aware of the Act, clinicians may change their contraceptive prescribing practices.

Immediate Postpartum Long-Acting Reversible Contraception: Review of Insertion and Device Reimbursement Policies

BACKGROUND

Previous assessment of statewide policies on long-acting reversible contraception (LARC) indicate that an increasing number of states are implementing policies specifically for provision immediately postpartum, supported by current clinical guidelines. Less is known about how state policies describe payment methodologies for the insertion procedure and device costs.

METHODS

We conducted a systematic, web-based review of publicly available statewide policy language on immediate postpartum LARC among all 50 states. We examined the payor/s identified in the policy and policy type, if the policy included language on the global obstetric fee, whether providers and/or facilities were authorized to bill for procedure or device costs, and if the billing mechanism was identified as inpatient and/or outpatient services.

RESULTS

Three-fourths of states (76%; n = 38) had statewide policies on immediate postpartum LARC. All policies identified Medicaid as the payor, although two also included non-Medicaid plans. Language allowing for reimbursement separate from the global obstetric fee for insertion procedures was present in 76% of states; 23 states permit it and 6 do not. Device cost reimbursement separate from the fee was identified in more state policies (92%); 31 states allow it and 4 do not. More policies included inpatient or outpatient billing mechanisms for device costs (82%; n = 31) than insertion procedures (50%; n = 19).

CONCLUSIONS

Medicaid reimbursement policies for immediate postpartum LARC services vary by state reimbursement process, type, and mechanism. Observed differences indicate payment methodologies more often include the cost of the device than provider reimbursement (31 states vs. 23 states). Fewer than one-half of states offer reimbursement for provider insertion fees, a significant systems barrier to contraceptive access for women who choose LARC immediately postpartum.

Social disadvantage and its effect on maternal and newborn health

Social disadvantage impacts the health of women and newborns throughout the life course. Contributing factors such as low educational attainment, unemployment, poverty, and lack of health insurance disproportionately affects minority women of reproductive age in the United States. This article reviews social disadvantage as it contributes to health status and health disparities for mothers and newborns in the United States and highlights the opportunities to improve social and structural determinants of health to address these gaps.

From training to implementation: Improving contraceptive practices in South Carolina

OBJECTIVE

Capacity building and training to improve contraceptive care is essential for patient-centered care and reproductive autonomy. This study assessed the feasibility of translating the knowledge and skills gained from contraception trainings into improvements in practice.

STUDY DESIGN

Participants completed surveys following contraceptive care trainings provided to family planning clinic and hospital obstetric providers and staff as a part of the Choose Well contraceptive access initiative in South Carolina. Surveys assessed participants' intent to change their practice post-training and anticipated barriers to implementing change. A mixed-methods approach was utilized including descriptive analysis of Likert scale responses and thematic content analysis to synthesize open-ended, qualitative responses.

RESULTS

Data were collected from 160 contraceptive training sessions provided to 4814 clinical and administrative staff between 2017 and 2019. Post-training surveys were completed by 3464 participants (72%), and of these, 2978 answered questions related to the study outcomes. Most respondents (n = 2390; 80.7%) indicated intent to change their practice and 35.5% (n = 1044) anticipated barriers to implementing intended changes. Across all training categories, organizational factors (time constraints, policies and practices, infrastructure/resources) were the most frequently perceived barrier to improving contraceptive services. Structural factors related to cost for patients were also identified as barriers to IUD and implant provision.

CONCLUSION

The trainings were successful in influencing family planning staff and providers' intent to improve their contraceptive practices, yet some anticipated barriers in translating training into practice. Improvements in organizational and structural policies are critical to realizing the benefits of trainings in advancing quality contraceptive care.

IMPLICATIONS

In addition to training, coordinated efforts to address organizational practices and resources, coupled with system-level policy changes are essential to facilitate the delivery and sustainability of patient-centered contraceptive care.

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.

Provision of Immediate Postpartum Long-Acting Reversible Contraceptives Before and After Wisconsin Medicaid's Payment Change

OBJECTIVES

We aimed to estimate the association between Medicaid unbundling of payment for long-acting reversible contraceptives (LARC) from the global delivery fee and immediate postpartum (IPP) LARC provision, in a state outside a select group of early-adopters. We also examine the potential moderating roles of hospital academic affiliation and Catholic status on the association between unbundling and IPP LARC provision.

METHODS

We used a pre-post design to examine the association between unbundling and IPP LARC provision. We observed Medicaid-covered childbirth deliveries in Wisconsin hospitals between January 2016 and December 2017 (n = 45,200) in the State Inpatient Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. We conducted multivariate regressions using generalized linear mixed models.

RESULTS

From 2016 to 2017, IPP LARC provision increased from 0.28% to 0.44% of deliveries (p = .003). In our adjusted model, IPP LARC provision was 1.55 times more likely in the post-period versus the pre-period (95% confidence interval, 1.12-2.13). Both before and after unbundling, IPP LARC provision was significantly more common in academic versus nonacademic settings and was exceedingly rare in Catholic institutions.

CONCLUSIONS

In contrast with many early adopting states, in this later adopting state, Wisconsin Medicaid's unbundling of LARC from the global fee did not meaningfully change the rates of IPP LARC provision. These results indicate that delivery hospital characteristics are strong correlates of access to IPP LARC and suggest the need for interventions-perhaps outside of the inpatient setting-to ensure that patients can access desired contraceptive methods promptly postpartum.

Medicaid Payments For Immediate Postpartum Long-Acting Reversible Contraception: Evidence From South Carolina

In 2012 South Carolina's Medicaid program was the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (intrauterine devices and contraceptive implants) from its global maternity payment. Examining data on all Medicaid-insured South Carolina women giving birth from 2010 to 2014, we found that the new policy achieved its explicit goal: increasing the availability of immediate postpartum long-acting reversible contraception. Among adolescents, for whom most pregnancies are unintended, this represented new use of long-acting reversible options, rather than substitution for sterilization or for short-acting reversible methods. Therefore, the new policy also significantly increased use of highly effective postpartum contraception in an age group that is particularly vulnerable to closely spaced, higher-risk repeat pregnancies. However, fewer than half of facilities began to offer immediate postpartum long-acting reversible contraceptives after the policy change. Additional policy approaches may be needed to achieve widespread availability of this option.

Advancing clinical leadership to improve the implementation of evidence-based practice in surgery: a longitudinal mixed-method study protocol

BACKGROUND

Clinical leadership is fundamental in facilitating service improvements in healthcare. Few studies have attempted to understand or model the different approaches to leadership which are used when promoting the uptake and implementation of evidence-based interventions. This research aims to uncover and explain how distributed clinical leadership can be developed and improved to enhance the use of evidence in practice. In doing so, this study examines implementation leadership in orthopaedic surgery to explain leadership as a collective endeavour which cannot be separated from the organisational context.

METHODS

A mixed-method study consisting of longitudinal and cross-sectional interviews and an embedded social network analysis will be performed in six NHS hospitals. A social network analysis will be undertaken in each hospital to uncover the organisational networks, the focal leadership actors and information flows in each organisation. This will be followed by a series of repeated semi-structured interviews, conducted over 4 years, with orthopaedic surgeons and their professional networks. These longitudinal interviews will be supplemented by cross-sectional interviews with the national established surgical leaders. All qualitative data will be analysed using a constructivist grounded theory approach and integrated with the quantitative data. The participant narratives will enrich the social network to uncover the leadership configurations which exist, and how different configurations of leadership are functioning in practice to influence implementation processes and outcomes.

DISCUSSION

The study findings will facilitate understanding about how and why different configurations of leadership develop and under what organisational conditions and circumstances they are able to flourish. The study will guide the development of leadership interventions that are grounded in the data and aimed at advancing leadership for service improvement in orthopaedics. The strength of the study lies in the combination of multi-component, multi-site, multi-agent methods to examine leadership processes in surgery. The findings may be limited by the practical challenges of longitudinal qualitative data collection, such as ensuring participant retention, which need to be balanced against the theoretical and empirical insights generated through this comprehensive exploration of leadership across and within a range of healthcare organisations.

Association of Insurance Status With Provision of Recommended Services During Comprehensive Postpartum Visits

IMPORTANCE

Improving care during the postpartum period is a clinical and policy priority. During the comprehensive postpartum visit, guidelines recommend delivery of a large number of assessment, screening, and counseling services. However, little is known about services provided during these visits.

OBJECTIVE

To examine rates of recommended services during the comprehensive postpartum visits and differences by insurance type.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 20 071 093 weighted office-based postpartum visits (645 observations) with obstetrical-gynecological or family medicine physicians from annual National Ambulatory Medical Care Surveys from December 28, 2008, to December 31, 2016, and estimated multivariate regression models to calculate the frequency of recommended services by insurance type, controlling for visit, patient, and physician characteristics. Data analysis was conducted from November 1, 2019, to September 1, 2020.

EXPOSURES

Visit paid by Medicaid vs other payment types.

MAIN OUTCOMES AND MEASURES

Visit length and binary indicators of blood pressure measurement, depression screening, contraceptive counseling or provision, pelvic examinations, Papanicolaou tests, breast examinations, medication ordered or provided, referral to other physician, and counseling for weight reduction, exercise, stress management, diet and/or nutrition, and tobacco use.

RESULTS

A total of 20 071 093 weighted comprehensive postpartum visits to office-based family medicine or obstetrical-gynecological physicians were included (mean patient age, 29.7 [95% CI, 29.1-30.3] years). Of these visits, 34.3% (95% CI, 27.6%-41.1%) were covered by Medicaid. Mean visit length was 17.4 (95% CI, 16.4-18.5) minutes. The most common procedures were blood pressure measurement (91.1% [95% CI, 88.0%-94.2%]), pelvic examinations (47.3% [95% CI, 40.8%-53.7%]), and contraception counseling or provision (43.8% [95% CI, 38.2%-49.3%]). Screening for depression (8.7% [95% CI, 4.1%-12.2%]) was less common. When controlling for visit, patient, and physician characteristics, the only significant difference in visit length or provision of recommended services based on insurance type was a difference in provision of breast examinations (14.7% [95% CI, 8.0%-21.5%] for Medicaid vs 25.6% [95% CI, 19.4%-31.8%] for non-Medicaid; P = .02).

CONCLUSIONS AND RELEVANCE

These findings suggest that receipt of recommended services during comprehensive postpartum visits is less than 50% for most services and is similar across insurance types. These findings underscore the importance of efforts to reconceptualize postpartum care to ensure women have access to a range of supports to manage their health during this sensitive period.

The role of pregnancy intendedness and prenatal contraceptive counseling on postpartum contraceptive use

Background

The study was conducted to prospectively examine how pregnancy intendedness and prenatal provider counseling about postpartum contraceptive options are associated with lack of contraception use at 6 months post-birth (e.g., increased risk for a short interpregnancy interval).

Methods

Logistic regression models were used to examine risk for no postpartum contraception use among a sample of low-income and racially/ethnically diverse women recruited from two metropolitan perinatal clinics in Tulsa, OK.

Results

Women who reported that they were trying to get pregnant or “okay either way” about getting pregnant had significantly lower odds of using contraception at 6 months post childbirth than those who had unintended pregnancies. Having providers who discussed postpartum contraceptive options during pregnancy significantly increased the odds of contraceptive uptake among those who were planning or ambivalent about their pregnancies.

Conclusions

Intentions of a current pregnancy and provider contraceptive counseling matter for postpartum contraceptive use and the associated risk for a short interval subsequent pregnancy. Provider contraceptive counseling that accounts for the intendedness of a current pregnancy may offer a more targeted approach to prevent a short interval subsequent pregnancy.

Variation in Postpartum Use of Most and Moderately Effective Contraceptive Methods Among Louisiana Women

BACKGROUND

Women experiencing unintended and short-interval pregnancies are at increased risk for adverse outcomes. Nationally, researchers report disparities in women's use of effective contraceptive methods based on demographic, cultural, financial and system-level factors. Despite 58% of Louisiana births being unplanned, researchers have not reported on these relationships in Louisiana.

METHODS

We used Louisiana Pregnancy Risk Assessment Monitoring System data from 2015 to 2018. Among postpartum women who were not abstinent, pregnant, or trying to become pregnant, we estimated use of five categories of effective contraception versus no effective method. We used multivariable multinomial logistic regression to investigate the association between effective contraceptive use and race/ethnicity, postpartum insurance and education.

RESULTS

Among Louisiana postpartum women who were not abstinent, pregnant, or trying to become pregnant, 35.4% were not using effective contraception. Women with public insurance had greater odds of using long-acting reversible contraception than women with private insurance (adjusted odds ratio [AOR] 1.55; 95% confidence interval [CI] 1.11-2.16). Compared to women with a bachelor's or higher, women with less than high school (AOR 2.09; CI 1.22-3.56), high school (AOR 3.11; CI 2.01-4.82) or some college education (AOR 2.48; CI 1.64-3.75) had greater odds of using permanent contraception. Black (AOR 3.83; CI 2.66-5.54) and Hispanic (AOR 3.85; CI 2.09-7.11) women, women with less than high school (AOR 6.79; CI 2.72-16.94), high school (AOR 7.26; CI 3.06-17.21) and some college (AOR 7.22; CI 3.14-16.60), and women with public insurance (AOR 1.91; CI 1.28-2.87) had greater odds of using injectable contraception.

DISCUSSION

Results showed variation in effective contraceptive method use by race/ethnicity, insurance and education. These findings highlight the need for state-level research into the individual, provider, and policy-level factors that influence women's contraceptive choices.

The cost of improving care: a multisite economic analysis of hospital resource use for implementing recommended postpartum contraception programmes

BACKGROUND

The costs of quality improvement efforts in real-world settings are often unquantified. Better understanding could guide appropriate resource utilisation and drive efficiency. Immediate postpartum contraceptive care (ie, placement of an intrauterine device or contraceptive implant during hospitalisation for childbirth) represents an excellent case study for examining costs, because recommended services are largely unavailable and adoption requires significant effort. We therefore evaluated the cost of implementing immediate postpartum contraceptive services at four academic centres and one private hospital in USA.

METHODS

In this mixed-methods cost analysis, implementation activities were retrospectively identified using standardised data collection. Activities were categorised as preimplementation activities (infrastructure building, tool creation and stakeholder engagement) or execution activities (workforce training and process refinement). Costs were assigned based on national median salaries for the roles of individuals involved. Cross-case comparison and rapid qualitative analysis guided by the Consolidated Framework for Implementation Research were used to identify factors driving cost variation observed across sites.

RESULTS

On average, implementation activities required 204 hours (range 119-368), with this time costing $14 433.94 (range $9955.61-$23 690.49), and involving 9 (range 7-11) key team members per site. Preimplementation activities required more resources than execution activities (preimplementation: average 173 hours, $11 573.25; execution: average 31 hours, $2860.67). Sites that used lower-cost employees (eg, shifting tasks from a physician to a project manager) observed lower costs per hour for implementation activities. Implementation activities and costs were associated with local contextual factors, including stakeholder acceptance, integration of employees and infrastructure readiness for the change effort.

CONCLUSIONS

Our findings provide the first estimates of health system costs for adopting recommended contraceptive care in maternity units in USA. More broadly, our findings suggest that the budget impact of improvement efforts may vary widely depending on local context.

Champions in context: which attributes matter for change efforts in healthcare?

Background

Research to date has focused on strategies and resources used by effective champions of healthcare change efforts, rather than personal characteristics that contribute to their success. We sought to identify and describe champion attributes influencing outcomes of healthcare change efforts. To examine attributes of champions, we used postpartum contraceptive care as a case study, because recommended services are largely unavailable, and implementation requires significant effort.

Methods

We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 U.S. maternity hospitals in 2017–18. We conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Phase one analysis (qualitative content analysis using a priori CFIR codes and cross-case synthesis) showed that implementation leaders (“champions”) strongly influenced outcomes across sites. To understand champion effects, phase two inductive analysis included (1) identifying and elaborating key attributes of champions; (2) rating the presence or absence of each attribute in champions; and 3) cross-case synthesis to identify patterns among attributes, context, and implementation outcomes.

Results

We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. All identified champions were obstetrician-gynecologists. Six key attributes of champions emerged: influence, ownership, physical presence at the point of change, persuasiveness, grit, and participative leadership style. These attributes promoted success by enabling champions to overcome institutional siloing, build and leverage professional networks, create tension for change, cultivate a positive learning climate, optimize compatibility with existing workflow, and engage key stakeholders. Not all champion attributes were required for success, and having all attributes did not guarantee success.

Conclusions

Effective champions appear to leverage six key attributes to facilitate healthcare change efforts. Prospective evaluations of the interactions among champion attributes, context, and outcomes may further elucidate how champions exert their effects.

An initiative to implement immediate postpartum long-acting reversible contraception in rural New Mexico

BACKGROUND

Over the past decade, many states have developed approaches to reimburse for immediate postpartum long-acting reversible contraception. Despite expanded coverage, few hospitals offer immediate postpartum long-acting reversible contraception.

OBJECTIVES

Immediate postpartum long-acting reversible contraception implementation is complex and requires a committed multidisciplinary team. After New Mexico Medicaid approved reimbursement for this service, the New Mexico Perinatal Collaborative developed and initiated an evidence-based implementation program containing several components. We sought to evaluate timing of the implementation process and facilitators and barriers to immediate postpartum long-acting reversible contraception in several New Mexico rural hospitals. The primary study outcome was time from New Mexico Perinatal Collaborative program component introduction in each hospital to the hospital's completion of the corresponding implementation step. Secondary outcomes included barriers and facilitators to immediate postpartum contraception implementation.

STUDY DESIGN

In this mixed-methods study, conducted from April 2017 to May 2018, we completed semistructured questionnaires and interviews with 20 key personnel from 7 New Mexico hospitals that planned to implement immediate postpartum long-acting reversible contraception. The New Mexico Perinatal Collaborative introduced program components to hospitals in a stepped-wedge design. Participants contributed baseline and follow-up data at 4 time periods detailing the steps taken towards program implementation and the timing of step completion at their hospital. Qualitative data were analyzed using directed qualitative content analysis principles based on the Consolidated Framework for Implementation Research.

RESULTS

Investigators conducted 43 interviews during the 14-month study period. Median time to complete steps toward implementation-patient education, clinician training, nursing education, charge capture, available supplies, and protocols or guidelines-ranged from 7 days for clinician training to 357 days to develop patient education materials. Facilitators of immediate postpartum contraception readiness were local hospital clinical champions and institutional administrative and financial stability. Of the 7 hospitals, 4 completed all Perinatal Collaborative implementation program components and 3 of those piloted immediate postpartum long-acting reversible contraception services. Two publicly funded hospitals currently offer immediate postpartum long-acting reversible contraception without verification of payment for the device or insertion. The third hospital piloted the program with 8 contraceptive devices, did not receive reimbursement due to identified flaws in Medicaid billing guidance and does not currently offer the service. The remaining 3 of the 7 hospitals declined to complete the NMPC program; the hospital that completed the program but did not pilot immediate postpartum long-acting reversible contraception did so because Medicaid billing mechanisms were incompatible with their automated billing systems. Participants consistently reported that lack of reimbursement was the major barrier to immediate postpartum long-acting reversible contraception implementation.

CONCLUSION

Despite the New Mexico Perinatal Collaborative's robust implementation process and hospital engagement, most hospitals did not offer immediate postpartum long-acting reversible contraception over the study period. Reimbursement obstacles prevented full service implementation. Interventions to improve immediate postpartum long-acting reversible contraception access must begin with implementation of seamless billing and reimbursement mechanisms to ensure adequate hospital payments.

Coverage of immediate postpartum long-acting reversible contraception has improved birth intervals for at-risk populations

BACKGROUND

In 2012, South Carolina revised the Medicaid policy to cover reimbursement for immediate postpartum long-acting reversible contraception. Immediate postpartum long-acting reversible contraception may improve health outcomes for populations at risk with a subsequent short-interval pregnancy.

OBJECTIVES

We examined the impact of the Medicaid policy change on the initiation of long-acting and reversible contraception (immediate postpartum and postpartum) within key populations. We determined whether immediate postpartum long-acting and reversible contraception use varied by adequate prenatal care (>7 visits), metropolitan location, and medical comorbidities. We also tested the association of immediate postpartum and postpartum long-acting, reversible contraception on interpregnancy interval of less than 18 months.

STUDY DESIGN

We conducted a historical cohort study of live births among Medicaid recipients in South Carolina between 2010 and 2017, 2 years before and 5 years after the policy change. We used birth certificate data linked with Medicaid claims. Our primary outcome was immediate postpartum long-acting and reversible contraception, and our secondary outcome was short interpregnancy interval. We characterize trends in long-acting and reversible contraception use and interpregnancy interval over the study period. We used logistic regression models to test the association of key factors (rural, inadequate prenatal care, and medical comorbidities) with immediate and outpatient postpartum long-acting and reversible contraception following the policy change and to test the association of immediate postpartum and postpartum long-acting and reversible contraception with short interpregnancy interval.

RESULTS

Our sample included 187,438 births to 145,973 women. Overall, 44.7% of the sample was white, with a mean age of 25.0 years. A majority of the sample (61.5%) was multiparous and resided in metropolitan areas (79.5%). The odds of receipt of immediate postpartum long-acting and reversible contraception use increased after the policy change (adjusted odds ratio, 1.39, 95% confidence interval, 1.34-1.43). Women with inadequate prenatal care (adjusted odds ratio, 1.50, 95% confidence interval, 1.31-1.71) and medically complex pregnancies had higher odds of receipt of immediate postpartum long-acting and reversible contraception following the policy change (adjusted odds ratio, 1.47, 95% confidence interval, 1.29-1.67) compared with women with adequate prenatal care and normal pregnancies. Women residing in rural areas were less likely to receive immediate postpartum long-acting and reversible contraception (adjusted odds ratio, 0.36, 95% confidence interval, 0.30-0.44) than women in metropolitan areas. Utilization of immediate postpartum long-acting and reversible contraception was associated with a decreased odds of a subsequent short interpregnancy interval (adjusted odds ratio, 0.62, 95% confidence interval, 0.44-0.89).

CONCLUSION

Women at risk of a subsequent pregnancy and complications (inadequate prenatal care and medical comorbidities) are more likely to receive immediate postpartum long-acting and reversible contraception following the policy change. Efforts are needed to improve access in rural areas.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

Implementing a Learning Collaborative Framework for States Working to Improve Outcomes for Vulnerable Populations: The Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community

The opioid crisis has impacted vulnerable populations, specifically pregnant and postpartum women, and infants prenatally exposed to substances, including infants with Neonatal Abstinence Syndrome. Lack of access to clinical and social services; potential stigma or discrimination; and lack of resources for provision of services, including screening and treatment, have impacted the health of these populations. In 2018, using a systems change approach, the Association of State and Territorial Health Officials (ASTHO) and the Centers for Disease Control and Prevention (CDC) convened an Opioid use disorder, Maternal outcomes, Neonatal abstinence syndrome Initiative Learning Community (OMNI LC) that included other federal agencies, national clinical and nonclinical organizations, and 12 state leadership groups. The purpose of the OMNI LC was to determine areas of focus and identify strategies and best practices for implementing systems change to improve maternal and infant outcomes associated with opioid use disorder (OUD) during the perinatal period. Activities included in-person convenings with policy goal action plan development, virtual learning sessions, intensive technical assistance (TA), and temporary field placements. The OMNI LC partnering agencies and state teams met bimonthly for the first year of the initiative. At the in-person convening, state teams identified barriers to developing and implementing systems change in activity-specific action plans within five areas of focus: financing and coverage; access to and coordination of quality services; provider training and awareness; ethical, legal, and social considerations; and data, monitoring, and evaluation. State teams also identified stakeholder partnerships as a necessary component of strategy development in all areas of focus. Four virtual learning sessions were conducted on the areas of focus identified by state teams, and ASTHO conducted three intensive TA opportunities, and five states were identified for temporary field placement. To successfully address the impact of the opioid crisis on pregnant and postpartum women and infants, states developed innovative strategies focused on increasing support, services, and resources. Moving forward, state teams will participate in two additional in-person meetings, continue to identify barriers to the work, refine and customize action plans, and set new goals, to effect broad-ranging systems change for these vulnerable populations.

Informing Policy Change: A Study of Rapid Repeat Pregnancy in Adolescents to Increase Access to Immediate Postpartum Contraception

Background: Rapid repeat pregnancy (RRP) is common among adolescents and is associated with adverse maternal and infant outcomes. Despite evidence that use of long-acting forms of contraception before hospital discharge can help minimize RRP rates, barriers to placement existed within the state of Indiana. We sought to determine state-specific RRP and induced abortion rates for adolescents based on chosen postpartum contraception to inform policy change. Methods: We examined a retrospective cohort of 227 adolescents (ages 12-18 years) who gave birth in Indiana between 2010 and 2012. Demographics, postpartum contraception, and subsequent pregnancies or abortions after the sentinel delivery were obtained. Rates of RRP based on type of immediate postpartum contraception, etonogestrel (ENG) contraceptive implant, depo-medroxyprogesterone acetate (DMPA) injection, and short-acting methods were compared. Bivariate and logistic regression analyses were conducted. Results: RRP rates were 3.7% for those with ENG contraceptive implant, 22.6% for those with DMPA, and 39.1% for those who choose short-acting methods (p = 0.01). Adolescents who did not choose an ENG contraceptive implant were significantly more likely to have an RRP (adjusted odds ratio [aOR] = 11.8, 95% confidence interval: 2.74-110.3), compared with other contraceptive methods, even after adjusting for covariates such as age, prior pregnancies, and postpartum visit attendance. Conclusions: Immediate postpartum receipt of ENG implant was significantly associated with a lower likelihood of RRP in adolescents in Indiana. These data facilitated state policy change regarding insurance reimbursement to improve statewide access for all women, regardless of age, showing how local data can inform policy change.

Factors associated with postpartum use of long-acting reversible contraception

BACKGROUND

Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception, including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low.

OBJECTIVES

We sought to estimate prevalence of long-acting reversible contraception use among postpartum women and examine factors associated with long-acting reversible contraception use among those using any reversible contraception.

STUDY DESIGN

We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of long-acting reversible contraception use in our sample (n = 143,335). We examined maternal factors associated with long-acting reversible contraception use among women using reversible contraception (n = 97,013) using multivariable logistic regression (long-acting reversible contraception vs other type of reversible contraception) and multinomial regression (long-acting reversible contraception vs other hormonal contraception and long-acting reversible contraception vs other nonhormonal contraception).

RESULTS

The prevalence of long-acting reversible contraception use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported long-acting reversible contraception use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum long-acting reversible contraception use vs use of another reversible contraceptive method included age ≤24 years (adjusted odds ratio = 1.43; 95% confidence interval = 1.33-1.54) and ≥35 years (adjusted odds ratio = 0.87; 95% confidence interval = 0.80-0.96) vs 25-34 years; public insurance (adjusted odds ratio = 1.15; 95% confidence interval = 1.08-1.24) and no insurance (adjusted odds ratio = 0.73; 95% confidence interval = 0.55-0.96) vs private insurance at delivery; having a recent unintended pregnancy (adjusted odds ratio = 1.44; 95% confidence interval = 1.34-1.54) or being unsure about the recent pregnancy (adjusted odds ratio = 1.29; 95% confidence interval = 1.18-1.40) vs recent pregnancy intended; having ≥1 previous live birth (adjusted odds ratio = 1.40; 95% confidence interval = 1.31-1.48); and having a postpartum check-up after recent live birth (adjusted odds ratio = 2.70; 95% confidence interval = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of long-acting reversible contraception use (26.6% and 23.4%, respectively) compared to non-Hispanic white women (21.5%), and there was significant race/ethnicity interaction with educational level.

CONCLUSION

Nearly 1 in 6 (15.3%) postpartum women with a recent live birth and nearly 1 in 4 (22.5%) postpartum women using reversible contraception reported long-acting reversible contraception use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum long-acting reversible contraception use. Ensuring all postpartum women have access to the full range of contraceptive methods, including long-acting reversible contraception, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of long-acting reversible contraception (and other methods), as well as providing full reimbursement for contraceptive services and removal of administrative and logistical barriers.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #48: Immediate postpartum long-acting reversible contraception for women at high risk for medical complications

Reproductive planning is essential for all women and most important for those with complex health conditions or at high risk for complications. Pregnancy planning can allow these high-risk women the opportunity to receive preconception counseling, medication adjustment, and risk assessment related to health conditions that have a direct impact on maternal morbidity and mortality risk. Despite the need for pregnancy planning, medically complex women face barriers to contraceptive use, including systemic barriers, such as underinsurance for women at increased risk for complex medical conditions as well as low uptake of effective postpartum contraception. Providing contraceptive counseling and a full range of contraceptive options, including immediate postpartum long-acting reversible contraception (LARC), is a means of overcoming these barriers. The purpose of this document is to educate all providers, including maternal-fetal medicine subspecialists, about the benefits of postpartum contraception, and to advocate for widespread implementation of immediate postpartum LARC placement programs. The following are Society for Maternal-Fetal Medicine recommendations: we recommend that LARC be offered to women at highest risk for adverse health events as a result of a future pregnancy (GRADE 1B); we recommend that obstetric care providers discuss the availability of immediate postpartum LARC with all pregnant women during prenatal care and consult the U.S. Medical Eligibility Criteria for Contraceptive Use guidelines to determine methods most appropriate for specific medical conditions (GRADE 1C); we recommend that women considering immediate postpartum intrauterine device insertion be counseled that although expulsion rates are higher than with delayed insertion, the benefits appear to outweigh the risk of expulsion, as the long-term continuation rates are higher (GRADE 1C); we recommend that obstetric care providers wishing to utilize immediate postpartum LARC obtain training specific to the immediate postpartum period (BEST PRACTICE); for women who desire and are eligible for LARC, we recommend immediate postpartum placement after a high-risk pregnancy over delayed placement due to overall superior efficacy and cost-effectiveness (GRADE 1B); we recommend that women considering immediate postpartum LARC be encouraged to breastfeed, as current evidence suggests that these methods do not negatively influence lactation (GRADE 1B); for women who desire and are eligible for LARC, we suggest that early postpartum LARC placement be considered when immediate postpartum LARC placement is not feasible (GRADE 2C); and we recommend that contraceptive counseling programs be patient-centered and provided in a shared decision-making framework to avoid coercion (BEST PRACTICE).

Contraceptive Choices in the Immediate Postpartum Period in Women With Cardiac Disease

Maternal cardiac disease (MCD) is associated with increased maternal and neonatal morbidity and mortality. Because unplanned pregnancies are especially risky, active use of reliable contraception is critical in this population. Studies in the noncardiac population have demonstrated that the postpartum period is an ideal time to address contraceptive plans. This retrospective cohort study was designed to describe contraceptive choices in women with MCD in the immediate postpartum period and to identify factors associated with specific contraceptive plans. We included women with MCD who delivered from January 2008 to September 2017 at a tertiary care institution with a multidisciplinary obstetrics and cardiology team. Maternal demographics, specifics of MCD, obstetrical outcomes, and contraceptive plans were obtained through chart review. Contraceptive plans were categorized into highly reliable methods (sterilization or long-acting reversible contraceptive methods) or less reliable methods (nonlong-acting reversible contraceptive methods or no contraception). In the 254 women included in this study, 40% planned to use highly reliable methods, while 60% planned to use less reliable methods. Women with cardiomyopathy were more likely to choose a highly reliable method of contraception (adjusted odds ratio 2.6, 95% confidence interval 1.2 to 5.7), a reassuring finding, given the particularly high risk of poor pregnancy outcome with this diagnosis. There were no differences in other cardiac diagnoses between the 2 contraceptive groups. In conclusion, the finding that <50% of postpartum women with MCD plan to use a highly reliable method of contraception warrants further examination to identify and address barriers to reliable contraceptive plans in this high-risk population.

Application of an Implementation Science Framework to Policies on Immediate Postpartum Long-Acting Reversible Contraception

OBJECTIVES

Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions with standard practice. The objective of our study was to demonstrate the usefulness of applying an implementation science framework-the Consolidated Framework for Implementation Research (CFIR)-to increase understanding of implementation of complex statewide public health initiatives, using the example of Medicaid immediate postpartum long-acting reversible contraception (LARC) policies.

METHODS

We conducted semistructured telephone interviews with the 13 state teams participating in the Immediate Postpartum LARC Learning Community. We asked teams to describe the implementation facilitators, barriers, and strategies in 8 focus areas of the Learning Community. We audio-recorded and transcribed interviews and then coded each interview according to the domains and constructs (ie, theoretical concepts) of the CFIR.

RESULTS

Cosmopolitanism (ie, networking with external organizations) was the most frequently coded construct of the framework. A related construct was networks and communications (ie, the nature and quality of social networks and formal and informal communications in an organization). Within the construct of cost, state teams identified barriers that were often unable to be overcome. Trialability (ie, ability to test the intervention on a small scale) and engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization) were among the most salient constructs of the framework and were the sources of many implementation strategies.

CONCLUSIONS

State leaders and program staff members may benefit from considering the CFIR domains and constructs in the planning, implementation, and evaluation of complex statewide public health initiatives.

State-Identified Implementation Strategies to Increase Uptake of Immediate Postpartum Long-Acting Reversible Contraception Policies

BACKGROUND

In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation.

MATERIALS AND METHODS

Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified.

RESULTS

The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities.

CONCLUSIONS

Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.