1
|
Rodriguez MI, Daly A, Meath T, Watson K, McConnell KJ. Catholic sole community hospitals are associated with decreased receipt of postpartum permanent contraception among Medicaid recipients. Contraception 2023; 122:109959. [PMID: 36708859 DOI: 10.1016/j.contraception.2023.109959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/03/2023] [Accepted: 01/14/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To examine the association of Catholic hospitals with receipt of postpartum tubal ligation and long acting, reversible contraception among Medicaid recipients. STUDY DESIGN We conducted a retrospective cohort study of live births from January 1, 2016 to October 31, 2016 to female Medicaid beneficiaries in the United States between ages 21 and 44. Our main exposure was the presence of a Catholic-affiliated sole community hospital, and our primary outcome was highly effective postpartum contraception. We examined rates of postpartum permanent contraception, along with the use of a long acting, reversible form of contraception (LARC) at 3 and 60 days are postpartum. We compared counties that had only a Catholic-affiliated hospital with counties with only a non-Catholic hospital. RESULTS Our study population included 14,545 postpartum Medicaid beneficiaries. Study participants came from 88 counties across 10 United States states. Only 7.7% of women in counties with Catholic sole community hospitals received permanent contraception by 3 days postpartum, compared to 11.3% in counties with non-Catholic sole community hospitals (RD: -3.92%; 95% CI: -6.01%, -1.83%). This difference was not mitigated by receipt of outpatient procedures or long-acting, reversible contraception. Importantly, women residing in counties with Catholic sole community hospitals were much less likely to return postpartum for an outpatient visit between 8 and 60 days postpartum than women in counties with non-Catholic sole community hospitals (35.4% vs 45.4%, RD: -9.29%; 95% CI: -16.71%, -1.86%). CONCLUSIONS In counties where the only hospital was Catholic, Medicaid recipients giving birth were significantly less likely to receive permanent contraception and to return for postpartum care. IMPLICATIONS Catholic hospitals are increasing in the United States, which may restrict access to postpartum contraception, particularly in rural areas. We found that Medicaid recipients giving birth at a Catholic sole community hospital were less likely to receive permanent contraception and to return for care.
Collapse
Affiliation(s)
- Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States.
| | - Ashley Daly
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Thomas Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Kelsey Watson
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, United States
| |
Collapse
|
2
|
Sweeney HE, Bainvoll L, Mandelbaum RS, Sangara RN, Violette CJ, Klar M, Matsushima K, Paulson RJ, Cahoon SS, Nguyen BT, Bender NM, Ouzounian JG, Matsuo K. Uptake of postplacental intrauterine device placement at cesarean delivery. AJOG GLOBAL REPORTS 2023; 3:100157. [PMID: 36748028 PMCID: PMC9898742 DOI: 10.1016/j.xagr.2022.100157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Several studies have investigated the effectiveness of intrauterine device placement at cesarean delivery as a contraceptive method. However, national-level use and outcomes of a postplacental intrauterine device at cesarean delivery are currently understudied in the United States. OBJECTIVE This study aimed to examine the trends, characteristics, and outcomes of patients who received a postplacental intrauterine device at cesarean delivery. STUDY DESIGN This retrospective cohort study used the National Inpatient Sample. The study cohort included patients who underwent cesarean delivery from October 2015 to December 2018. The exclusion criteria included hemorrhage, chorioamnionitis, uterine anomaly, hysterectomy, and permanent surgical sterilization. Eligible cases were grouped on the basis of the use of a postplacental intrauterine device at cesarean delivery. The primary outcome measures were temporal trends and characteristics associated with the use of a postplacental intrauterine device at cesarean delivery, assessed using the generalized estimating equation model in multivariable analysis. The secondary outcome measure was perioperative morbidity (leukocytosis, endometritis, myometritis, and sepsis). Propensity score matching was used to balance the baseline characteristics. RESULTS Among 2,983,978 patients who met the inclusion criteria, 10,145 patients (0.3%) received a postplacental intrauterine device at cesarean delivery. The use of a postplacental intrauterine device increased from 0.1% in the fourth quarter of 2015 to 0.6% in the fourth quarter of 2018 (P<.001). In a multivariable analysis, the use of a postplacental intrauterine device increased by 14% every quarter-year (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.15). In addition, (1) patient characteristics of young age, non-White race, obesity, tobacco use, lowest quartile median household income, and insured with Medicaid; (2) hospital characteristics of large bed capacity and urban teaching setting in Northeast region; and (3) pregnancy characteristics of early gestational age at cesarean delivery, hypertensive disease, previous cesarean delivery, multifetal pregnancy, grand multiparity, placenta previa, and nonelective cesarean delivery represented the independent characteristics associated with the use of a postplacental intrauterine device (all P<.05). A regression tree model identified 35 discrete patterns of the use of a postplacental intrauterine device based on 8 factors (time, race or ethnicity, primary expected payer, obesity, hospital bed capacity, hospital teaching status, hospital region, and previous cesarean delivery). There were 9 patterns, representing 8.8% of the study population, exhibiting a use rate of ≥1.0%, whereas there were 7 patterns, representing 16.0% of the study population, exhibiting no use of a postplacental intrauterine device (absolute rate difference from the highest group to the lowest group, 4.7%). In a propensity score-matched model, postplacental intrauterine device placement at cesarean delivery was not associated with increased risk of measured morbidity (any, 1.8% vs 1.7%; odds ratio, 1.06; 95% confidence interval, 0.66-1.69; P=.812), including postpartum endometritis (1.2% vs 1.0%; odds ratio, 1.19; 95% confidence interval, 0.67-2.14; P=.554). CONCLUSION The use of a postplacental intrauterine device at cesarean delivery increased significantly in recent years in the United States.
Collapse
Affiliation(s)
- Heather E. Sweeney
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Sweeney, Ms Bainvoll, and Drs Mandelbaum, Sangara, Violette, and Matsuo)
| | - Liat Bainvoll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Sweeney, Ms Bainvoll, and Drs Mandelbaum, Sangara, Violette, and Matsuo),Keck School of Medicine, University of Southern California, Los Angeles, CA (Ms Bainvoll)
| | - Rachel S. Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Sweeney, Ms Bainvoll, and Drs Mandelbaum, Sangara, Violette, and Matsuo),Division of Reproductive Endocrinology and Infertility, University of Southern California, Los Angeles, CA (Drs Mandelbaum and Paulson)
| | - Rauvynne N. Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Sweeney, Ms Bainvoll, and Drs Mandelbaum, Sangara, Violette, and Matsuo)
| | - Caroline J. Violette
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Sweeney, Ms Bainvoll, and Drs Mandelbaum, Sangara, Violette, and Matsuo)
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg Faculty of Medicine, Freiburg, Germany (Dr Klar)
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA (Dr Matsushima)
| | - Richard J. Paulson
- Division of Reproductive Endocrinology and Infertility, University of Southern California, Los Angeles, CA (Drs Mandelbaum and Paulson)
| | - Sigita S. Cahoon
- Division of Obstetrics, Gynecology, and Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Cahoon)
| | - Brian T. Nguyen
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Drs Nguyen and Bender)
| | - Nicole M. Bender
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Drs Nguyen and Bender)
| | - Joseph G. Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Ouzounian)
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Sweeney, Ms Bainvoll, and Drs Mandelbaum, Sangara, Violette, and Matsuo),Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (Dr Matsuo),Corresponding author: Koji Matsuo, MD, PhD.
| |
Collapse
|
3
|
Manalew W, Hale N, Leinaar E, Sen B, Smith M, Khoury A. Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018. Popul Health Manag 2022; 25:542-550. [DOI: 10.1089/pop.2021.0392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- W.Samuel Manalew
- Department of Health Services Management and Policy and Center for Applied Research and Evaluation in Women's Health, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Nathan Hale
- Department of Health Services Management and Policy and Center for Applied Research and Evaluation in Women's Health, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Edward Leinaar
- Department of Health Services Management and Policy and Center for Applied Research and Evaluation in Women's Health, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Bisakha Sen
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Michael Smith
- Department of Health Services Management and Policy and Center for Applied Research and Evaluation in Women's Health, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Amal Khoury
- Department of Health Services Management and Policy and Center for Applied Research and Evaluation in Women's Health, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| |
Collapse
|
4
|
Making the financial case for immediate postpartum intrauterine device: a budget impact analysis. Am J Obstet Gynecol 2022; 226:702.e1-702.e10. [PMID: 34801445 DOI: 10.1016/j.ajog.2021.11.1348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/24/2021] [Accepted: 11/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement. OBJECTIVE The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing. STUDY DESIGN Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost. RESULTS Although an inpatient intrauterine device placement's upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement. CONCLUSION For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.
Collapse
|
5
|
Abdel-Ghany A, Khalifa E, El-Din MZ, Ibrahim E, Abdallah A, Abdel-Aziz M, Abdel-Rasheed M, Abdel-Azim A. Intrapartum versus postpartum insertion of intrauterine device in women delivering by cesarean section. BMC Pregnancy Childbirth 2022; 22:365. [PMID: 35484530 PMCID: PMC9047375 DOI: 10.1186/s12884-022-04681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The intrauterine device (IUD), being a reversible and effective contraception method, is the most widely used worldwide. This study aims to demonstrate the efficacy of IUD insertion during elective lower segment cesarean section (LSCS) versus its insertion six weeks postpartum. METHODS A cohort study was conducted on 200 women planned for elective cesarean delivery and desired IUD as a contraceptive method. They were allocated into two groups; group I, in which IUD was inserted during LSCS, and group II, in which IUD was inserted six weeks or more after LSCS. Both groups were compared regarding failed insertion, post-insertion pain, and uterine perforation. They were followed for one year for the incidence of menorrhagia, vaginal infection, IUD displacement/expulsion, missed threads, or unintended pregnancy. RESULTS Women in the second group showed a significantly higher incidence of failed insertion and uterine perforation than women in the first group. On the contrary, women in the first group showed a significantly higher incidence of missed threads than women in the second group. Regarding other consequences, there were no significant differences between both groups concerning menorrhagia, vaginal infection, IUD displacement/expulsion, or unintended pregnancy. CONCLUSION IUD insertion during elective LSCS showed a significantly lower incidence of failed insertion and uterine perforation than its insertion six weeks postoperative.
Collapse
Affiliation(s)
- Ahmed Abdel-Ghany
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Eissa Khalifa
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Mohamed Zeen El-Din
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Emad Ibrahim
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Ameer Abdallah
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Mahmoud Abdel-Aziz
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| | - Mazen Abdel-Rasheed
- Reproductive Health Research Department, National Research Centre, 33 El-Buhouth St, Dokki, Cairo, 12622, Egypt.
| | - Alaa Abdel-Azim
- Obstetrics and Gynecology Department, Faculty of Medicine, MINIA University, Minya, Egypt
| |
Collapse
|
6
|
Taylor RAM, Yang JM, Cheney K, Black K. Short interpregnancy interval: circumstance or choice? BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:110-116. [PMID: 34649962 DOI: 10.1136/bmjsrh-2021-201269] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Despite the knowledge of pregnancy risks attributable to inadequate birth spacing, over one-third of pregnancies occur within 18 months of a preceding birth. In this qualitative study we sought to interview women with a short interpregnancy interval (sIPI) to explore their knowledge of contraception and birth spacing and their experience of counselling on these themes. METHODS We conducted in-depth interviews with women with a sIPI (live-birth less than 18 months prior to conception of current pregnancy) at Royal Prince Alfred Hospital and Canterbury Hospital in Sydney, Australia. Women were recruited at the second antenatal visit or day 3 postpartum. Interviews were recorded and transcribed. The six-phase thematic analysis framework described by Braun and Clarke was used to perform qualitative data analysis. RESULTS Twenty women were interviewed (IPI range: 3-18 months). The three central themes that arose were that perceptions of IPIs are shaped by individual circumstances, a lack of information from healthcare providers (HCPs) on IPI and contraception limited women's ability to make informed decisions, and that reproductive life planning is an important element of pregnancy care. CONCLUSIONS In this study, women with a sIPI did not feel informed about birth spacing, had poor knowledge of reliable contraceptives, and remained at risk of further closely spaced pregnancies. There was a desire among women with a sIPI to receive clear and consistent education on these topics. HCPs need to do more to educate women in the antenatal and postnatal period to help them space their pregnancies appropriately.
Collapse
Affiliation(s)
| | - Jenny M Yang
- Women and Babies, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kate Cheney
- Faculty of Medicine and Health, The University of Sydney Central Clinical School, Sydney, New South Wales, Australia
| | - Kirsten Black
- Faculty of Medicine and Health, The University of Sydney Central Clinical School, Sydney, New South Wales, Australia
| |
Collapse
|
7
|
Wilson CH, Lazorwitz A, Hyer J, Guiahi M. Concordance of Desired and Administered Postpartum Contraceptives among Emergency and Full Scope Medicaid Patients. Womens Health Issues 2022; 32:343-351. [PMID: 35272884 DOI: 10.1016/j.whi.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine if concordance of contraceptive preference and uptake differ between postpartum recipients of emergency versus full scope Medicaid. STUDY DESIGN We performed a historical cohort study of patients who delivered at a safety-net hospital in Denver, Colorado in 2016. In our public system, all patients had access to immediate postpartum tubal ligation and all forms of reversible contraception in outpatient clinics. We used data from electronic health records to compare contraceptive preferences and uptake between patients with full scope and emergency Medicaid at hospital discharge and by 12 weeks postpartum. We then compared contraceptive concordance (use of the same method as desired during delivery admission) between the groups at time of postpartum discharge and by 12 weeks postpartum. RESULTS We examined 693 women; 349 (50.1%) had emergency Medicaid and 344 (49.9%) had full scope Medicaid. The mean age at delivery was 27.9 years, and most patients were Hispanic (74%). Women with emergency Medicaid were less likely to receive their desired method of postpartum contraception before hospital discharge (53.6% vs. 66.9%; p < .01). One-half of the patients with emergency Medicaid who did not receive their desired method of immediate postpartum contraception were unable to obtain it based on insurance ineligibility. By 12 weeks postpartum, the rates of concordance did not differ by insurance status: 52.4% of patients with emergency Medicaid and 55.2% of patients with full scope Medicaid received their desired method of contraception (p = .46). CONCLUSIONS Emergency Medicaid recipients, largely recent and/or unauthorized immigrants, have high demand for highly effective postpartum contraceptives. Although emergency Medicaid recipients initially had lower rates of receipt of their desired contraceptive during the hospital stay compared with those with full scope Medicaid, they ultimately had similar concordance rates by 12 weeks postpartum. We suspect this finding was in part due to free access to all methods of contraception in our outpatient clinics during the postpartum course. Systemic barriers should be reduced to ensure better access to postpartum contraceptives for all patients, regardless of insurance coverage, to improve reproductive equity.
Collapse
Affiliation(s)
- Carrie H Wilson
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado.
| | - Aaron Lazorwitz
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer Hyer
- Department of Obstetrics and Gynecology, Denver Health Medical Center, Denver, Colorado
| | - Maryam Guiahi
- Planned Parenthood California Central Coast, Santa Barbara, California
| |
Collapse
|
8
|
Nsiah I, Mali NV, Barnard M, Goswami S, Lyle C, Ramachandran S. The Influence of Social Determinants of Health on the Provision of Postpartum Contraceptives in Medicaid. Healthcare (Basel) 2022; 10:healthcare10020298. [PMID: 35206912 PMCID: PMC8871824 DOI: 10.3390/healthcare10020298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 12/10/2022] Open
Abstract
Disparities continue to exist in the timely provision of postpartum contraception. This study aimed to identify prevalence and factors associated with postpartum contraception provision among women enrolled in Medicaid. A retrospective cohort study was conducted using the 2014 National Medicaid data, linked to county-level social vulnerability index (SVI) data. Women aged 15–44 with a live birth in 2014 were included. Multivariable logistic regression was used to predict 3-day provision of long-acting reversible contraception (LARC) and 60-day provision of most effective or moderately effective contraceptives (MMEC). Overall, 3-day LARC provision was 0.2% while 60-day MMEC was 36.3%. Significantly lower odds of receiving MMEC was found among women aged 15–20 (adjusted odds ratio [aOR] = 0.87; 95% CI:0.86–0.89) compared to women 20–44 years as well as among Asian women (aOR = 0.69; 95% CI:0.66–0.72) and Hispanic women (aOR = 0.73; 95% CI:0.72–0.75) compared to White women. The provision of postpartum contraception remains low, generally, and needs attention in communities experiencing poor maternal outcomes.
Collapse
Affiliation(s)
- Irene Nsiah
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
| | - Nidhi Vij Mali
- Department of Public Policy Leadership, University of Mississippi, Oxford, MS 38677, USA;
| | - Marie Barnard
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
| | - Swarnali Goswami
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
| | - Christy Lyle
- Gainwell Technologies, 381 Highland Colony Parkway, Ridgeland, MS 39157, USA;
| | - Sujith Ramachandran
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS 38677, USA; (I.N.); (M.B.); (S.G.)
- Center for Pharmaceutical Marketing & Management, University of Mississippi School of Pharmacy, Oxford, MS 38677, USA
- Correspondence:
| |
Collapse
|
9
|
Rodriguez MI, McConnell KJ, Skye M, Kaufman M, Caughey AB, Lopez-Defede A, Darney BG. Disparities in postpartum contraceptive use among immigrant women with restricted Medicaid benefits. AJOG GLOBAL REPORTS 2022; 2:100030. [PMID: 36274968 PMCID: PMC9563385 DOI: 10.1016/j.xagr.2021.100030] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Emergency Medicaid program offers restricted Medicaid benefits for people who meet the same financial eligibility criteria as Traditional Medicaid recipients but do not meet the citizenship requirements for enrollment in Traditional Medicaid. By federal law, Emergency Medicaid covers care for life-threatening emergencies or a hospital admission for childbirth. No prenatal or postpartum care is covered. Most of the women enrolled in Emergency Medicaid are Latina. OBJECTIVE We assessed postpartum visits and receipt of postpartum contraception and compared the outcomes for Emergency (restricted benefit) Medicaid recipients with those of Traditional (full-benefit) Medicaid recipients in Oregon and South Carolina, 2 states with similar-sized immigrant populations. STUDY DESIGN We conducted a retrospective cohort study using linked Medicaid claims and birth certificate data of live births covered by Medicaid (Traditional and Emergency) between January 1, 2010 and September 30, 2017, in Oregon and South Carolina. Our analysis was at the individual level. Primary outcomes were postpartum visit attendance and receipt of postpartum contraception within 2 months. We examined differences in demographic and delivery characteristics by Medicaid type. If women received postpartum contraception, we compared the timing of receipt (immediate postpartum, ≤1 month, 1–2 months, and 2–6 months after delivery) by the type of Medicaid. Among women using contraception, we described the type of contraceptive received at each time point, stratified by Medicaid type. Associations between Medicaid type (Traditional vs Emergency) and postpartum visit attendance and contraception use were assessed using adjusted absolute predicted probabilities from logistic regression models. We ran models for the entire cohort and conducted a subanalysis restricted to only Latina women. RESULTS Our study included 375,544 live births to 288,234 women, with 12.7% of births among Emergency Medicaid recipients. Women enrolled in Emergency Medicaid tended to be older (age >35 years; 18.1% vs 7.2%; P<.001) and were more likely to be multiparous (76.8% vs 60.8%; P<.001) and Latina (80.3% vs 9.5%; P<.001) than their Traditional Medicaid peers. Among women enrolled in Emergency Medicaid, the probability of having a postpartum visit was 6.1% (95% confidence interval, 5.9–6.4) compared with 58.8% (95% confidence interval, 58.6–58.9) for women covered by Traditional Medicaid. After 6 months following delivery, 97.6% of Emergency Medicaid recipients had no evidence of contraceptive use compared with 55.6% of Traditional Medicaid enrollees (P<.001). In our adjusted model, Emergency Medicaid recipients were also significantly less likely to receive postpartum contraception than Traditional Medicaid enrollees (1.9% vs 35.5%; 95% confidence interval, [1.8–2.1] vs [35.4–35.7]). We examined the role that race may play in postpartum contraceptive use by conducting a subanalysis restricted to Latina women only. Latinas with births covered by Emergency Medicaid had a 1.9% (95% confidence interval, 1.8–2.0) adjusted probability of postpartum contraception use within 2 months compared with 39.8% (95% confidence interval, 38.7–39.9) among Latinas enrolled in Traditional Medicaid. CONCLUSION Women enrolled in Emergency Medicaid experience large disparities in postpartum care and contraceptive use. Policies that restrict Medicaid coverage following delivery exacerbate inequities in postpartum care, potentially leading to worse health outcomes for low-income immigrants and their children.
Collapse
|
10
|
Rodriguez MI, Skye M, Lindner S, Caughey AB, Lopez-DeFede A, Darney BG, McConnell KJ. Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care. JAMA Netw Open 2021; 4:e2138983. [PMID: 34910148 PMCID: PMC8674744 DOI: 10.1001/jamanetworkopen.2021.38983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid. OBJECTIVE To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception. DESIGN, SETTING, AND PARTICIPANTS This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021. EXPOSURES Medicaid coverage of postpartum care. MAIN OUTCOMES AND MEASURES Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery. RESULTS The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.
Collapse
Affiliation(s)
- Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Megan Skye
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Stephan Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Ana Lopez-DeFede
- Institute for Families in Society, University of South Carolina, Columbia
| | - Blair G. Darney
- Divisionof Complex Family Planning, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| |
Collapse
|
11
|
Using the Social-Ecological Model to Understand the Current Perspective of Contraceptive Use in the United States: A Narrative Literature Review. WOMEN 2021. [DOI: 10.3390/women1040019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Contraceptive use is deemed one of the 10 greatest public health achievements of the 20th century because its benefits are universally acknowledged as a cornerstone for reducing global maternal morbidity and mortality. However, although the adoption of the Affordable Care Act in the United States (US) enhanced access to preventive health services, as well as increased contraceptive use, a considerable proportion of reproductive-aged women still have unmet reproductive health needs. Current data indicates gaps in contraceptive use patterns in the US, particularly among low-income women and those from racial/ethnic and gender minority subgroups, necessitating further investigation using an ecological approach. This narrative literature review aims to investigate the current perspective of contraceptive use in the US using the social-ecological model (SEM). Based on SEM levels, barriers to contraceptive use entail the following levels: individual (e.g., misbelief about the side effects of contraceptives), interpersonal (e.g., influence of family and friends), institutional (e.g., lack of training on how to use different types of contraceptives), community (e.g., societal stigma and shame), and policy (e.g., restrictive federal and states policies). Access to contraceptives for women is a system-level issue that necessitates consideration for multilevel strategies by key stakeholders to improve contraceptive uptake among vulnerable populations.
Collapse
|
12
|
Zhang Y, Sheth S, Weidner AKH, Egwuatu P, Webb L, Shih G. Immediate Postpartum IUD Training Within a Regional Network of Family Medicine Residencies. PRIMER (LEAWOOD, KAN.) 2021; 5:24. [PMID: 34286227 PMCID: PMC8284491 DOI: 10.22454/primer.2021.421778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Immediate postpartum placement of intrauterine devices (PPIUD) offers important benefits to patients. Little is known about PPIUD training or knowledge within family medicine residency programs. We evaluated PPIUD experience and prior training among family medicine residents and faculty. METHODS We conducted a cross-sectional survey of residents and faculty in 24 regional family medicine residency programs in 2018. Survey questions focused on reception of PPIUD training and experience with PPIUD counseling and placement. RESULTS The final survey sample included 203 residents and 100 faculty with an overall response rate of 39%. About 26% (n=79) of all participants reported receiving prior training for counseling and placement of PPIUDs, while 16% (n=48) of participants had ever placed a PPIUD. Twenty-six percent (n=78) of participants reported that their residency programs offered PPIUD training. Residents and faculty who reported past PPIUD training and/or placement experience were more likely to have ever counseled patients about PPIUD (P<.001) and report that their primary training hospital offered PPIUD to patients (P<.001) and their residency programs offered PPIUD training (P<.001). CONCLUSIONS Few programs offer routine PPIUD training opportunities for family medicine residents and faculty, which may contribute to limited availability of PPIUD to patients. There is a need to improve PPIUD training and placement opportunities for both family medicine residents and faculty.
Collapse
Affiliation(s)
- Ying Zhang
- University of Washington, Family Medicine Department, Seattle, WA
| | - Sonali Sheth
- University of Washington, Family Medicine Department, Seattle, WA
| | - Amanda K H Weidner
- University of Washington Family Medicine Residency Network, Department of Family Medicine
| | - Patricia Egwuatu
- University of Washington, Family Medicine Department, Seattle, WA
| | - Lauren Webb
- University of Washington, Family Medicine Department, Seattle, WA
| | - Grace Shih
- University of Washington, Family Medicine Department, Seattle, WA | and University of Washington, Family Medicine Department, Seattle, WA
| |
Collapse
|
13
|
White A, Srinivasan M, Wingate LM, Peasah S, Fleming M. Development of a pharmacoeconomic registry: an example using hormonal contraceptives. HEALTH ECONOMICS REVIEW 2021; 11:10. [PMID: 33745016 PMCID: PMC7981865 DOI: 10.1186/s13561-021-00309-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Disease-specific registries, documenting costs and probabilities from pharmacoeconomic studies along with health state utility values from quality-of-life studies could serve as a resource to guide researchers in evaluating the published literature and in the conduct of future economic evaluations for their own research. Registries cataloging economic evaluations currently exist, however they are restricted by the type of economic evaluations they include. There is a need for intervention-specific registries, that document all types of complete and partial economic evaluations and auxiliary information such as quality of life studies. The objective of this study is to describe the development of a pharmacoeconomic registry and provide best practices using an example of hormonal contraceptives. METHODS An expert panel consisting of researchers with expertise in pharmacoeconomics and outcomes research was convened and the clinical focus of the registry was finalized after extensive discussion. A list of key continuous, categorical and descriptive variables was developed to capture all relevant data with each variable defined in a data dictionary. A web-based data collection tool was designed to capture and store the resulting metadata. A keyword based search strategy was developed to retrieve the published sources of literature. Finally, articles were screened for relevancy and data was extracted to populate the registry. Expert opinions were taken from the panel at each stage to arrive at consensus and ensure validity of the registry. RESULTS The registry focused on economic evaluation literature of hormonal contraceptives used for contraception. The registry consisted of 65 articles comprising of 22 cost-effectiveness analyses, 9 cost-utility analyses, 7 cost-benefit analyses, 1 cost-minimization, 14 cost analyses, 10 cost of illness studies and 2 quality of life studies. The best practices followed in the development of the registry were summarized as recommendations. The completed registry, data dictionary and associated data files can be accessed in the supplementary information files. CONCLUSION This registry is a comprehensive database of economic evaluations, including costs, clinical probabilities and health-state utility estimates. The collated data captured from published information in this registry can be used to identify trends in the literature, conduct systematic reviews and meta-analysis and develop novel pharmacoeconomic models.
Collapse
Affiliation(s)
- Annesha White
- University of North Texas System College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX 76107 USA
- Department of Pharmacotherapy, UNT System College of Pharmacy, 3500 Camp Bowie Blvd, IREB 211, Fort Worth, TX 76107 USA
| | - Meenakshi Srinivasan
- University of North Texas System College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX 76107 USA
| | | | - Samuel Peasah
- Mercer University College of Pharmacy, Atlanta, GA 30341 USA
| | - Marc Fleming
- University of North Texas System College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX 76107 USA
| |
Collapse
|
14
|
Kim CS, Lunde B, MacIsaac L, Arden M, Garney WR, Wilson KL, Li Y. Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis. Contraception 2020; 103:107-112. [PMID: 33221276 DOI: 10.1016/j.contraception.2020.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/13/2020] [Accepted: 11/15/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City. STUDY DESIGN We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only. RESULTS The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs. CONCLUSION Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.
Collapse
Affiliation(s)
- Chi-Son Kim
- Department of Obstetrics and Gynecology, Stamford Hospital, Stamford, CT, United States.
| | - Britt Lunde
- Division of Family Planning, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Laura MacIsaac
- Division of Family Planning, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Martha Arden
- Division of Adolescent Medicine, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, NY, United States
| | - Whitney R Garney
- College of Education and Human Development, Department of Health and Kinesiology, Texas A&M University, College Station, TX, United States
| | - Kelly L Wilson
- College of Education and Human Development, Department of Health and Kinesiology, Texas A&M University, College Station, TX, United States
| | - Yan Li
- Department of Population Health Science and Policy, Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| |
Collapse
|
15
|
Welch EK, Lindberg M, Mauney D, McLeod F. Bring back the tubal: An intervention to provide postpartum tubal ligation in the underserved population. Health Care Women Int 2020; 45:113-128. [PMID: 32897839 DOI: 10.1080/07399332.2020.1805747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
We aimed to improve educational awareness of postpartum bilateral tubal ligation (PPBTL), which we defined as a 15% improvement between pre-/post-intervention questionnaire scores. We followed patients desiring and undergoing PPBTL and reason for unfulfilled procedures from 2017-2018. OB/GYN, Nursing, and Anesthesia participated in educational sessions with pre-/post-intervention questionnaires. Comparing the first and latter six months after study initiation, PPBTLs performed increased from 39% to 54%. Fifty-two staff participated in the interventions, with a 21% improvement in scores (OB/GYN p = 0.0117, Nursing p = 0.0001, Anesthesia p = 0.0002). We conclude multidisciplinary interventions improved educational awareness, an integral part to increasing PPBTL performance in the underserved.
Collapse
Affiliation(s)
- Eva K Welch
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
- Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Mary Lindberg
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Donald Mauney
- Department of Anesthesiology, Geisinger Health System, Wilkes Barre, Pennsylvania, USA
| | - Francine McLeod
- Department of Obstetrics & Gynecology, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| |
Collapse
|
16
|
Ling VB, Levi EE, Harrington AR, Zite NB, Rivas SD, Dalton VK, Smith R, Moniz MH. The cost of improving care: a multisite economic analysis of hospital resource use for implementing recommended postpartum contraception programmes. BMJ Qual Saf 2020; 30:658-667. [PMID: 32878968 DOI: 10.1136/bmjqs-2020-011111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/17/2020] [Accepted: 08/03/2020] [Indexed: 01/19/2023]
Abstract
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.
Collapse
Affiliation(s)
- Vivian B Ling
- School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Erika E Levi
- Obstetrics & Gynecology and Women's Health, Yeshiva University Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amy R Harrington
- Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York, USA
| | - Nikki B Zite
- Obstetrics & Gynecology, University of Tennessee Knoxville Graduate School of Medicine, Knoxville, Tennessee, USA
| | - Saul D Rivas
- Obstetrics and Gynecology, University of Texas Rio Grande Valley, Brownsville, Texas, USA
| | - Vanessa K Dalton
- Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Roger Smith
- Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michelle H Moniz
- Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
17
|
Extending Delivery Coverage to Include Prenatal Care for Low-Income, Immigrant Women Is a Cost-Effective Strategy. Womens Health Issues 2020; 30:240-247. [DOI: 10.1016/j.whi.2020.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 02/09/2020] [Accepted: 02/28/2020] [Indexed: 11/17/2022]
|
18
|
Hinz EK, Murthy A, Wang B, Ryan N, Ades V. A prospective cohort study comparing expulsion after postplacental insertion: the levonorgestrel versus the copper intrauterine device. Contraception 2019; 100:101-105. [DOI: 10.1016/j.contraception.2019.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
|
19
|
Bullard KA, Edelman AB, Williams SM, Rodriguez MI. Ulipristal acetate compared to levonorgestrel emergency contraception among current oral contraceptive users: a cost-effectiveness analysis. Contraception 2019; 100:222-227. [PMID: 31102631 DOI: 10.1016/j.contraception.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 04/09/2019] [Accepted: 05/07/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of ulipristal acetate (UPA) and levonorgestrel (LNG) emergency contraception (EC) on pregnancy prevention among combined oral contraceptive (COC) pill users with an extended pill-free interval. We accounted for the potential interaction of COCs and obesity on EC efficacy. METHODS We built a decision-analytic model using TreeAge software to evaluate the optimal oral EC strategy in a hypothetical cohort of 100,000 twenty-five-year-old women midcycle with a prolonged "missed" pill episode (8-14 days). We used a 5-year time horizon and 3% discount rate. From a healthcare perspective, we obtained probabilities, utilities and costs inflated to 2018 dollars from the literature. We set the threshold for cost-effectiveness at a standard $100,000 per quality-adjusted life-year. We included the following clinical outcomes: number of protected cycles, unintended pregnancies, abortions, deliveries and costs. RESULTS We found that UPA was the optimal method of oral EC, as it resulted in 720 fewer unintended pregnancies, 736 fewer abortions and 80 fewer deliveries at a total cost savings of $50,323 and 79 additional adjusted life-years. UPA continued to be the optimal strategy even in the case of obesity or COCs impacting UPA efficacy, in which a COC interaction would have to change efficacy of UPA by 160% before LNG was the dominant strategy. CONCLUSION Our models found that UPA was the dominant choice of oral EC among COC users with a prolonged "missed" pill episode, regardless of body mass index or an adverse interaction of COCs on UPA. IMPLICATIONS Ulipristal acetate is the dominant choice of oral emergency contraception among combined oral contraceptive users.
Collapse
Affiliation(s)
- Kimberley A Bullard
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon.
| | - Alison B Edelman
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Shannon M Williams
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Maria I Rodriguez
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
20
|
Thwaites A, Tran AB, Mann S. Women's and healthcare professionals' views on immediate postnatal contraception provision: a literature review. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:88-94. [PMID: 31000571 DOI: 10.1136/bmjsrh-2018-200231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/21/2019] [Accepted: 03/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Provision of immediate postnatal contraception, including long-acting reversible contraceptive (LARC) methods, is increasingly identified and endorsed as a key strategy for reducing unplanned and rapid repeat pregnancies. This literature review aims to evaluatethe views of women and healthcare professionals regarding the receipt, initiation or delivery of these services. METHODS Databases (Embase, Medline, CINAHL, HMIC) were searched for relevant English language studies, from January2003 to December 2017. In addition, Evidence Search, Google Scholar and Scopus (citation search) were used to identify further literature. Other relevant websites were accessed for policies, guidance and supplementary grey literature. RESULTS There is clear guidance on how to deliver good-quality postnatal contraception to women, but the reality of service delivery in the UK does not currently meet these aspirations, and guidance on implementation is lacking. The available evidence on the provision of immediate postnatal contraception focuses more on clinical rather than patient-centred outcomes. Research on postnatal women's views is limited to receptivity to LARC and contraception counselling rather than what influences their decision-making process at this time. Research on views of healthcare professionals highlights a range of key systemic barriers to implementation. CONCLUSIONS While views of postnatal women and healthcare professionals are largely in support of immediate postnatal contraception provision, important challenges have been raised and present a need for national sharing of service commissioning and delivery models, resources and evaluation data. Provider attitudes and training needs across multidisciplinary groups also need to be assessed and addressed as collaborative working across a motivated, skilled and up-to-date network of healthcare professionals is viewed as key to successful service implementation.
Collapse
Affiliation(s)
- Annette Thwaites
- EGA Institute for Women's Health, University College London, London, UK
| | | | - Sue Mann
- Public Health England, London, UK
| |
Collapse
|
21
|
Lynch M, De Abreu Lourenco R, Flattery M, Haas M. Reviewing the cost-effectiveness of long-acting reversible contraceptive methods in an Australian context. Aust N Z J Obstet Gynaecol 2018; 59:21-35. [PMID: 30311634 DOI: 10.1111/ajo.12906] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Relative to the oral contraceptive pill, uptake of long-acting reversible contraceptive methods (LARCs) in Australia continues to be lower than might be suggested by the evidence on their clinical and economic benefits. AIM To undertake a critical appraisal of published economic evaluations of LARCs to assess the generalisability of their results to the Australian healthcare context. MATERIALS AND METHODS A search of the literature was conducted to identify studies of economic evaluations of LARCs using the Medline, Embase and PubMed databases. The quality of the studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS A total of 1009 citations were screened, from which 20 papers, typically reporting the cost per pregnancy avoided, were reviewed. The overall quality of the studies varied but was generally poor (average score of 62/100). To aid comparisons, results have been grouped under the headings IUS (all hormonal intrauterine systems), IUDs (all non-hormonal intrauterine devices), injectables (all contraceptive injections) and implants (all subdermal contraceptive implants). Overall, the results indicated that LARCs were more effective and less costly than oral contraceptives. CONCLUSIONS Despite evidence that LARCs represent value for money, limitations in study quality and approaches must be taken into account when applying these results to Australia. Differences in healthcare settings aside, LARCs may also have benefits beyond their effect on pregnancy that might be captured in broader analyses, such as cost-benefit analyses using willingness to pay methods. These would capture benefits beyond health, which seem to be particularly relevant to contraception.
Collapse
Affiliation(s)
- Matthew Lynch
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| | - Martin Flattery
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| | - Marion Haas
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| |
Collapse
|
22
|
Goldthwaite LM, Cahill EP, Voedisch AJ, Blumenthal PD. Postpartum intrauterine devices: clinical and programmatic review. Am J Obstet Gynecol 2018; 219:235-241. [PMID: 30031750 DOI: 10.1016/j.ajog.2018.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/05/2018] [Accepted: 07/08/2018] [Indexed: 10/28/2022]
Abstract
The immediate postpartum period is a critical moment for contraceptive access and an opportunity to initiate long-acting reversible contraception, which includes the insertion of an intrauterine device. The use of the intrauterine device in the postpartum period is a safe practice with few contraindications and many benefits. Although an intrauterine device placed during the postpartum period is more likely to expel compared with one placed at the postpartum visit, women who initiate intrauterine devices at the time of delivery are also more likely to continue to use an intrauterine device compared with women who plan to follow up for an interval intrauterine device insertion. This review will focus on the most recent clinical and programmatic updates on postpartum intrauterine device practice. We discuss postpartum intrauterine device expulsion and continuation, eligibility criteria and contraindications, safety in regards to breastfeeding, and barriers to access. Our aim is to summarize evidence related to postpartum intrauterine devices and encourage those involved in the healthcare system to remove barriers to this worthwhile practice.
Collapse
|
23
|
Whitaker AK, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices. Contraception 2018; 97:2-13. [DOI: 10.1016/j.contraception.2017.09.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 01/09/2023]
|
24
|
McKenzie C, Akdagli S, Abir G, Carvalho B. Postpartum tubal ligation: A retrospective review of anesthetic management at a single institution and a practice survey of academic institutions. J Clin Anesth 2017; 43:39-46. [PMID: 28985581 DOI: 10.1016/j.jclinane.2017.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/02/2017] [Accepted: 09/23/2017] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE The primary aim was to evaluate institutional anesthetic techniques utilized for postpartum tubal ligation (PPTL). Secondarily, academic institutions were surveyed on their clinical practice for PPTL. DESIGN An institutional-specific retrospective review of patients with ICD-9 procedure codes for PPTL over a 2-year period was conducted. Obstetric anesthesia fellowship directors were surveyed on anesthetic management of PPTL. SETTING Labor and delivery unit. Internet survey. PATIENTS 202 PPTL procedures were reviewed. 47 institutions were surveyed; 26 responses were received. MEASUREMENTS Timing of PPTL, anesthetic management, postoperative pain and length of stay. MAIN RESULTS There was an epidural catheter reactivation failure rate of 26% (18/69 epidural catheter reactivation attempts). Time from epidural catheter insertion to PPTL was a significant factor associated with failure: median [IQR; range] time for successful versus failed epidural catheter reactivation was 17h [10-25; 3-55] and 28h [14-33; 5-42], respectively (P=0.028). Epidural catheter reactivation failure led to significantly longer times to provide surgical anesthesia than successful epidural catheter reactivation or primary spinal technique: median [IQR] 41min [33-54] versus 15min [12-21] and 19min [15-24], respectively (P<0.0001). Fifty-eight percent (15/26) of respondents routinely leave the labor epidural catheter in-situ if PPTL is planned. Sixty-five percent (17/26) and 7% (2/26) would not attempt to reactivate the epidural catheter for PPTL if >8h and >24h post-delivery, respectively. CONCLUSIONS Epidural catheter reactivation failure increases with longer intervals between catheter placement and PPTL. Failed epidural catheter reactivation increases anesthetic and operating room times. Our results and the significant variability in practice from our survey suggest recommendations on the timing and anesthetic management are needed to reduce unfulfilled PPTL procedures.
Collapse
Affiliation(s)
- Christine McKenzie
- Department of Anesthesiology, UNC Medical Center, 101 Manning Drive, Chapel Hill, NC 27516, United States
| | - Seden Akdagli
- Department of Anesthesiology, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - Gillian Abir
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, United States.
| |
Collapse
|
25
|
Moniz MH, Roosevelt L, Crissman HP, Kobernik EK, Dalton VK, Heisler MH, Low LK. Immediate Postpartum Contraception: A Survey Needs Assessment of a National Sample of Midwives. J Midwifery Womens Health 2017; 62:538-544. [PMID: 28881464 PMCID: PMC5924570 DOI: 10.1111/jmwh.12653] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/05/2017] [Accepted: 06/13/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Immediate postpartum long-acting, reversible contraception (LARC)-providing intrauterine devices (IUDs) and contraceptive implants immediately following birth-is an effective strategy to prevent unintended pregnancies and improve birth spacing. We measured US certified nurse-midwives' (CNMs') and certified midwives' (CMs') knowledge, training needs, current practice, and perceived barriers to providing immediate postpartum LARC. METHODS We invited currently practicing CNM and CM members of the American College of Nurse-Midwives to complete an online survey about their knowledge and experience with the use of LARC and analyzed eligible questionnaires using descriptive statistics. RESULTS Of 4609 eligible midwives, 794 responded (17% response rate). Most were female (99.5%) and non-Hispanic white (92.1%), with 45.0% attending births in urban settings. Responses revealed multiple knowledge gaps related to IUD expulsion rates and appropriateness of immediate postpartum LARC in certain clinical scenarios. Only 10.1% of respondents reported feeling confident to insert an immediate postpartum IUD and 43.3% an implant. Many reported desiring additional training in immediate postpartum IUD (63.5%) and implant (22.8%) insertion; few reported access to such training (IUD, 19.9%; implant, 15.2%). Most respondents had never inserted an immediate postpartum IUD (90.7%) or implant (86.8%). The most commonly cited barriers to immediate postpartum LARC provision were that it is not standard practice (IUD, 40.9%; implant, 39.0%) or is not available (IUD, 27.8%; implant, 34.8%) at one's institution and feeling inadequately trained (IUD, 26.5%; implant, 10.7%). DISCUSSION Nine in 10 midwife respondents have never inserted an IUD or implant immediately postpartum, but more than half indicated they would like the opportunity to provide these services. Our findings highlight opportunities to enhance the immediate postpartum LARC-related knowledge and skills of the midwife workforce. They also suggest that logistic and institutional barriers to immediate postpartum LARC access must be removed in order to make this evidence-based reproductive health service available to all women who desire it.
Collapse
|
26
|
Abstract
Immediate postpartum long-acting reversible contraception (LARC) has the potential to reduce unintended and short-interval pregnancy. Women should be counseled about all forms of postpartum contraception in a context that allows informed decision making. Immediate postpartum LARC should be offered as an effective option for postpartum contraception; there are few contraindications to postpartum intrauterine devices and implants. Obstetrician-gynecologists and other obstetric care providers should discuss LARC during the antepartum period and counsel all pregnant women about options for immediate postpartum initiation. Education and institutional protocols are needed to raise clinician awareness and to improve access to immediate postpartum LARC insertion. Obstetrician-gynecologists and other obstetric care providers should incorporate immediate postpartum LARC into their practices, counsel women appropriately about advantages and risks, and advocate for institutional and payment policy changes to support provision.
Collapse
|
27
|
Immediate postpartum long-acting reversible contraception: the time is now. Contraception 2016; 95:335-338. [PMID: 27913231 DOI: 10.1016/j.contraception.2016.11.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/11/2016] [Accepted: 11/22/2016] [Indexed: 11/21/2022]
|
28
|
Moniz MH, Dalton VK, Davis MM, Forman J, Iott B, Landgraf J, Chang T. Characterization of Medicaid policy for immediate postpartum contraception. Contraception 2015; 92:523-31. [PMID: 26452327 DOI: 10.1016/j.contraception.2015.09.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Long-acting reversible contraception (LARC) is safe, effective and cost-saving when provided immediately postpartum but currently underutilized due to nonreimbursement by Medicaid and other insurers. The objectives of this study were to (a) determine which state Medicaid agencies provide specific reimbursement for immediate postpartum LARC and (b) identify modifiable policy-level barriers and facilitators of immediate postpartum LARC access. STUDY DESIGN We conducted semistructured telephone interviews with representatives of 40 Medicaid agencies to characterize payment methodology for immediate postpartum LARC. We coded transcripts using grounded theory and content analysis principles. RESULTS Three categories of immediate postpartum LARC payment methodology emerged: state Medicaid agency (a) provides separate or increased bundled payment (n=15), (b) is considering providing enhanced payment (n=9) or (c) is not considering enhanced payment (n=16). Two major themes emerged related to Medicaid decision-making about immediate postpartum LARC coverage: (a) Health effects: States with payment for immediate postpartum LARC frequently cited improved maternal/child health outcomes as motivating their reimbursements. Conversely, states without payment expressed misinformation about LARC's clinical effects and lack of advocacy from local providers about clinical need for this service. (b) Financial implications: States providing payment emphasized overall cost savings. Conversely, states without reimbursement expressed concern about immediate budget constraints and potential adverse impact on existing global payment methodology for inpatient care. CONCLUSIONS Many states have recently provided Medicaid coverage of immediate postpartum LARC, and several other states are considering such coverage. Addressing misinformation about clinical effects and concerns about cost-effectiveness of immediate postpartum LARC may promote adoption of immediate postpartum LARC reimbursement in Medicaid agencies currently without it. IMPLICATIONS Medicaid policy for reimbursement of immediate postpartum LARC is evolving rapidly across the US. Our findings suggest several concrete strategies to remove policy-level barriers and promote facilitators of immediate postpartum LARC.
Collapse
Affiliation(s)
- Michelle H Moniz
- Department of Obstetrics and Gynecology, Ann Arbor, MI, USA; Robert Wood Johnson Foundation Clinical Scholars®, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.
| | - Vanessa K Dalton
- Department of Obstetrics and Gynecology, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Matthew M Davis
- Robert Wood Johnson Foundation Clinical Scholars®, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA; Department of Internal Medicine, Ann Arbor, MI, USA; Department of Pediatrics and Communicable Diseases, Ann Arbor, MI, USA; Department of Health Management and Policy, School of Public Health, Ann Arbor, MI, USA; Gerald R. Ford School of Public Policy, Ann Arbor, MI, USA
| | - Jane Forman
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Bradley Iott
- Robert Wood Johnson Foundation Clinical Scholars®, Ann Arbor, MI, USA
| | - Jessica Landgraf
- Robert Wood Johnson Foundation Clinical Scholars®, Ann Arbor, MI, USA
| | - Tammy Chang
- Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA; Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
29
|
Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act. Curr Opin Obstet Gynecol 2015; 26:531-8. [PMID: 25379769 DOI: 10.1097/gco.0000000000000119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To summarize the newest available evidence on maternal and reproductive health disparities, and to describe elements of the Affordable Care Act most likely to impact these disparities. RECENT FINDINGS Significant racial and ethnic disparities in maternal and reproductive health outcomes have persisted in recent years, contributing to poor outcomes and increasing costs. Pregnancy-related mortality ratios are up to three times higher in Black women compared with non-Hispanic White women, with the risk of severe maternal morbidity also significantly higher in Black and Hispanic women. Unintended pregnancy is twice as likely in minority women. Insurance status, socioeconomic status, and broader social determinants of health are implicated in these disparities. Coverage changes associated with the Affordable Care Act may provide some opportunities to reach communities most at risk. Delivery innovation, payment reform, and further public financing of key services are examples of further management approaches that can be used to address reproductive health disparities. SUMMARY The Affordable Care Act offers important opportunities to address persistent reproductive health disparities, but significant gaps remain. Efforts must be made to reduce the negative outcomes and high financial and human costs associated with disparities in reproductive health.
Collapse
|
30
|
Levi EE, Stuart GS, Zerden ML, Garrett JM, Bryant AG. Intrauterine Device Placement During Cesarean Delivery and Continued Use 6 Months Postpartum: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:5-11. [PMID: 26241250 PMCID: PMC5354629 DOI: 10.1097/aog.0000000000000882] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare intrauterine device (IUD) use at 6 months postpartum among women who underwent intracesarean delivery (during cesarean delivery) IUD placement compared with women who planned for interval IUD placement 6 or more weeks postpartum. METHODS In this nonblinded randomized trial, women who were undergoing a cesarean delivery and desired an IUD were randomized to intracesarean delivery or interval IUD placement. The primary outcome was IUD use at 6 months postpartum. A sample size of 112 (56 in each group) was planned to detect a 15% difference in IUD use at 6 months postpartum between groups. RESULTS From March 2012 to June 2014, 172 women were screened and 112 women were randomized into the trial. Baseline characteristics were similar between groups. Data regarding IUD use at 6 months postpartum were available for 98 women, 48 and 50 women in the intracesarean delivery and interval groups, respectively. A larger proportion of the women in the intracesarean delivery group were using an IUD at 6 months postpartum (40/48 [83%]) compared with those in the interval group (32/50 [64%], relative risk 1.3, 95% confidence interval 1.02-1.66). Among the 56 women randomized to interval IUD insertion, 22 (39%) of them never received an IUD; 14 (25%) never returned for IUD placement, five (9%) women declined an IUD, and three (5%) had a failed IUD placement. CONCLUSION Intrauterine device placement at the time of cesarean delivery leads to a higher proportion of IUD use at 6 months postpartum when compared with interval IUD placement. LEVEL OF EVIDENCE I.
Collapse
Affiliation(s)
- Erika E Levi
- Division of Family Planning and Global Health, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gretchen S Stuart
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Matthew L Zerden
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Joanne M Garrett
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Amy G Bryant
- Division of Family Planning, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
31
|
Aiken ARA, Creinin MD, Kaunitz AM, Nelson AL, Trussell J. Global fee prohibits postpartum provision of the most effective reversible contraceptives. Contraception 2014; 90:466-7. [PMID: 25212061 PMCID: PMC4179975 DOI: 10.1016/j.contraception.2014.08.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 08/06/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Abigail R A Aiken
- Office of Population Research, Princeton University, Princeton, NJ, USA.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Anita L Nelson
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
| | - James Trussell
- Office of Population Research, Princeton University, Princeton, NJ, USA
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW In this era of healthcare reform, attention is focused on increasing the quality of care and access to services, while simultaneously reducing the cost. Economic evaluations can play an important role in translating research to evidence-based practice and policy. RECENT FINDINGS Cost-effectiveness analysis (CEA) and its utility for clinical and policy decision making among U.S. obstetricians and gynecologists is reviewed. Three case examples demonstrating the value of this methodology in decision making are considered. A discussion of the methodologic principles of CEA, the advantages, and the limitations of the methodology are presented. SUMMARY CEA can play an important role in evidence-based decision making, with value for clinicians and policy makers alike. These studies are of particular interest in the field of obstetrics and gynecology, in which uncertainty from epidemiologic or clinical trials exists, or multiple perspectives need to be considered (maternal, neonatal, and societal). As with all research, it is essential that economic evaluations are conducted according to established methodologic standards. Interpretation and application of results should occur with a clear understanding of both the value and the limitations of economic evaluations.
Collapse
|
33
|
Han L, Teal SB, Sheeder J, Tocce K. Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective? Am J Obstet Gynecol 2014; 211:24.e1-7. [PMID: 24631431 DOI: 10.1016/j.ajog.2014.03.015] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 02/07/2014] [Accepted: 03/06/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of the study was to determine the cost-effectiveness of a hypothetical state-funded program offering immediate postpartum implant (IPI) insertion for adolescent mothers. STUDY DESIGN Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, n = 171) vs standard contraceptive initiation (comparison group, n = 225). Implant discontinuation, repeat pregnancies and pregnancy outcomes were determined. We compared the anticipated public expenditures for IPI recipients and comparisons at 6, 12, 24, and 36 months postpartum using the actual outcomes of this cohort and Colorado Medicaid reimbursement estimates. Costs were normalized to 1000 adolescents in each arm and included 1 year of well-baby care for delivered pregnancies. RESULTS At 6 months, the expenditures of the IPI group exceed the comparison group by $73,000. However, at 12, 24, and 36 months, publicly funded IPIs would result in a savings of more than $550,000, $2.5 million, and $4.5 million, respectively. For every dollar spent on the IPI program, $0.79, $3.54, and $6.50 would be saved at 12, 24, and 36 months. Expenditures between the IPI and comparison groups would be equal if the comparison group pregnancy rate was 13.8%, 18.6%, and 30.5% at 12, 24, and 36 months. Actual rates were 20.1%, 46.5%, and 83.7%. CONCLUSION Offering IPIs to adolescent mothers is cost effective. Payors that do not currently cover IPI should integrate these data into policy considerations.
Collapse
|
34
|
Wilson S, Tennant C, Sammel MD, Schreiber C. Immediate postpartum etonogestrel implant: a contraception option with long-term continuation. Contraception 2014; 90:259-64. [PMID: 24993485 DOI: 10.1016/j.contraception.2014.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 05/01/2014] [Accepted: 05/04/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine 3-year continuation rates of the etonogestrel contraceptive implant when inserted immediately postpartum and to identify factors associated with discontinuation. STUDY DESIGN A retrospective cohort of 262 women who had the contraceptive implant inserted immediately postpartum between January 2008 and March 2009 was collected from electronic medical records. Continuation rates at 1, 2 and 3 years were estimated. Adverse effects leading to removal of the implant were recorded. Multivariable Cox proportional hazard models were performed to determine factors associated with early discontinuation. RESULTS Large subsets of the study patients were adolescent (28.2%) and multigravid (71.8%) and presented for fewer than six prenatal visits (38.5%). Follow-up rates were over 70% at each of the 3 years. Adolescents and women with fewer than six prenatal visits had the highest continuation rates at 1 year, 94.5% and 94.1%, respectively. The cumulative implant continuation rate after 3 years was 66.3%. Multivariable analysis indicated that having six or more prenatal care visits was the only independent predictor of early discontinuation, with a hazard ratio of 3.1 (p=0.04) and 1.8 (p=<0.01) at 1 and 3 years, respectively. The most commonly reported reasons for early removal were abnormal bleeding (41.2%) and weight gain (19.1%). CONCLUSION The contraceptive implant has high continuation over its 3-year lifespan when inserted immediately postpartum. Continuation rates were highest among populations most vulnerable to rapid repeat and unintended pregnancies. IMPLICATIONS The etonogestrel implant, when placed immediately postpartum for contraception, can have high continuation rates of use for up to 3 years duration.
Collapse
Affiliation(s)
| | | | - Mary D Sammel
- Department of Biostatistics and Epidemiology & Center for Clinical Epidemiology and Biostatistics (CCEB), Perelman School of Medicine, University of Pennsylvania
| | | |
Collapse
|
35
|
Postpartum contraception: optimizing interpregnancy intervals. Contraception 2014; 89:487-8. [PMID: 24815100 DOI: 10.1016/j.contraception.2014.04.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 04/25/2014] [Indexed: 11/20/2022]
|
36
|
Nelson AL. Postpartum contraception: a new frontier (again). J Womens Health (Larchmt) 2014; 23:193-4. [PMID: 24559240 DOI: 10.1089/jwh.2014.4735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anita L Nelson
- Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center , Manhattan Beach, California
| |
Collapse
|
37
|
Simmons KB, Edelman AB, Li H, Yanit KE, Jensen JT. Personalized contraceptive assistance and uptake of long-acting, reversible contraceptives by postpartum women: a randomized, controlled trial. Contraception 2013; 88:45-51. [DOI: 10.1016/j.contraception.2012.10.037] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/26/2012] [Accepted: 10/31/2012] [Indexed: 11/29/2022]
|
38
|
Levi E, Cantillo E, Ades V, Banks E, Murthy A. Immediate postplacental IUD insertion at cesarean delivery: a prospective cohort study. Contraception 2012; 86:102-5. [PMID: 22264666 DOI: 10.1016/j.contraception.2011.11.019] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 11/22/2011] [Accepted: 11/23/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immediate postplacental insertion of intrauterine devices (IUDs) during cesarean delivery could reduce a substantial barrier to access to long-term effective contraception. Initiating IUD use prior to discharge from the hospital postpartum eliminates a 6-week postpartum waiting period and an additional office visit. STUDY DESIGN This was a prospective cohort study of 90 patients undergoing cesarean delivery. After delivery of the placenta, a copper T380A IUD was inserted into the endometrial cavity through the incision. The study participants were followed up at 6 weeks and 6 months postpartum. This study was conducted at the Weiler Division of the Montefiore Medical Center and at the Jacobi Medical Center in the Bronx, NY. RESULTS Forty-three (48%) women returned for their 6-week follow-up visits, and among those, no expulsions were recorded. Forty-two (47%) women were reached for phone follow-up at 6 months postpartum, and 80% reported being "happy" or "very happy" with their IUD. CONCLUSIONS Immediate postplacental IUD insertion at the time of cesarean delivery is safe and acceptable.
Collapse
Affiliation(s)
- Erika Levi
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, Chapel Hill, NC 27514, USA.
| | | | | | | | | |
Collapse
|
39
|
Baldwin MK, Rodriguez MI, Edelman AB. Lack of insurance and parity influence choice between long-acting reversible contraception and sterilization in women postpregnancy. Contraception 2012; 86:42-7. [PMID: 22240179 DOI: 10.1016/j.contraception.2011.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 11/14/2011] [Accepted: 11/15/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Disparities in postpregnancy contraception utilization exist, with low-income women disproportionately undergoing sterilization. We assessed the impact of increased intrauterine device (IUD) availability on rates of female sterilization. STUDY DESIGN Hospital billing records were used to identify women with an IUD placement or sterilization within 1 year of a pregnancy at a university hospital between Oct 2005 and Jun 2007. Demographic data were compared between women receiving either an IUD or sterilization. RESULTS There were 365 sterilizations and 223 IUD placements during the study period. IUD placements doubled over the study period from 6% to 12% of all deliveries, while sterilizations remained stable at 11% (p<.001). Demographic variables were examined for women with either public or private insurance who had financial access to both sterilization (n=253) and IUD (n=223). Women receiving sterilization were slightly older (mean age 31 years versus 30 years, p=.03), of higher parity (median three versus two, p<.01), more likely to have had cesarean delivery (69% versus 31%, p<.001) and more likely to have public insurance (77% versus 23%, p<.001) than women who received IUD. Approximately 45% of women delivering in Oregon in 2007 were publicly insured (2010 Maternal and Child Health Update: States Make Progress Towards Improving Systems of Care. National Governor's Association, Table 6. Available at http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF, accessed Nov 2011). After adjusting for age, parity and type of delivery, women choosing sterilization were more likely to have public insurance than women choosing IUD (odds ratio 8.4, 95% confidence interval 4.7-14.9, p<.0001). CONCLUSIONS Women choosing sterilization are more likely to have public insurance than women choosing IUD and may represent a continued trend toward nonreversible contraception among women of lower socioeconomic status despite available long-acting reversible methods.
Collapse
Affiliation(s)
- Maureen K Baldwin
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR 97239, USA.
| | | | | |
Collapse
|
40
|
Landy U, Darney PD. The future of contraception: the future leaders of family planning. Am J Obstet Gynecol 2011; 205:S29-33. [PMID: 21961823 DOI: 10.1016/j.ajog.2011.06.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 06/02/2011] [Accepted: 06/10/2011] [Indexed: 10/17/2022]
Abstract
The University of California, San Francisco, initiated a Fellowship in Family Planning in 1991, and since then 23 academic teaching hospitals across the country have adopted the 2 year program model for training obstetrician-gynecologist physicians in a subspecialty focused on contraception and abortion. The program follows a curriculum that includes clinical practice, research, and international work. This review includes information about the Fellowship in Family Planning as well as research opportunities available from academia, independent foundations, and government related sources.
Collapse
|