1
|
Allison BA, Ritter V, Lin FC, Flower KB, Perry MF. Trends in Continuation of Long-Acting Reversible Contraception Among Adolescents Receiving Medicaid. J Adolesc Health 2024; 75:487-495. [PMID: 38980246 PMCID: PMC11330372 DOI: 10.1016/j.jadohealth.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/28/2024] [Accepted: 04/25/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Despite increasing use of long-acting reversible contraception (LARC) among U.S. adolescents, there is limited literature on factors affecting intrauterine device (IUD) or subdermal implant use. This study aimed to describe statewide rates, and associated patient and provider factors of adolescent IUD or implant initiation and continuation. METHODS This retrospective cohort study used N.C. Medicaid claims data. 10,408 adolescents were eligible (i.e., 13-19 years, female sex, continuous Medicaid enrollment, had an IUD or implant insertion or removal code from January 1, 2013, to October 1, 2015). Bivariate analyses assessed differences in adolescents using IUD versus implant. Kaplan-Meier curves were created to assess IUD or implant discontinuation through December 31, 2018. RESULTS Adolescents initiated 8,592 implants and 3,369 IUDs (N = 11,961). There were significant differences in nearly all provider and patient factors for those who initiated implants versus IUDs. 16% of implants and 53% of IUDs were removed in the first year. Younger (i.e., age <18 years old), Hispanic, and Black adolescents had higher adjusted continuation of implants compared with older and White adolescents, respectively (both p < .001). Those whose IUD was inserted by an obstetrician/gynecologist provider had lower continuation of IUDs compared with non-obstetrician/gynecologist providers (p < .001). DISCUSSION We found that age-related, racial, and ethnic disparities exist in both implant and IUD continuation. Practice changes to support positive adolescent experiences with implant and IUD insertion and removals are needed, including patient-centered health care provider training in contraception counseling, LARC initiation and removal training for adolescent-facing providers, and broader clinic capacity for LARC services.
Collapse
Affiliation(s)
- Bianca A Allison
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Victor Ritter
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina; Quantitative Sciences Unit, Stanford School of Medicine, Palo Alto, California
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Kori B Flower
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Martha F Perry
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Children's National, Washington, D.C
| |
Collapse
|
2
|
Goldin Evans M, Gee RE, Phillippi S, Sothern M, Theall KP, Wightkin J. Multilevel Barriers to Long-Acting Reversible Contraceptive Uptake: A Narrative Review. Health Promot Pract 2024; 25:717-725. [PMID: 37978809 DOI: 10.1177/15248399231211531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Unintended pregnancies, which occur in almost half (45%) of all pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives (LARCs), namely intrauterine devices and implants. Although LARCs are highly acceptable to women at risk of unintended pregnancies, barriers to accessing LARCs hinder its uptake. These barriers are greater among racial and socioeconomic lines and persist within and across the intrapersonal, interpersonal, institutional, and policy levels. A synthesis of these barriers is unavailable in the current literature but would be beneficial to health care providers of reproductive-aged women, clinical managers, and policymakers seeking to provide equitable reproductive health care services. The aim of this narrative review was to aggregate these complex and overlapping barriers into a concise document that examines: (a) patient, provider, clinic, and policy factors associated with LARC access among populations at risk of unintended pregnancy and (b) the clinical implications of mitigating these barriers to provide equitable reproductive health care services. This review outlines numerous barriers to LARC uptake across multiple levels and demonstrates that LARC uptake is possible when the woman is informed of her contraceptive choices and when financial and clinical barriers are minimized. Equitable reproductive health care services entail unbiased counseling, a full range of contraceptive options, and patient autonomy in contraceptive choice.
Collapse
Affiliation(s)
- Melissa Goldin Evans
- Mary Amelia Center for Women's Health Equity Research, Tulane University, New Orleans, LA, USA
| | | | - Stephen Phillippi
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Melinda Sothern
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Katherine P Theall
- Mary Amelia Center for Women's Health Equity Research, Tulane University, New Orleans, LA, USA
| | - Joan Wightkin
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| |
Collapse
|
3
|
Wells R, Smith NK. Usual Source of Care and Contraceptive Use. Med Care 2024; 62:79-86. [PMID: 37962413 DOI: 10.1097/mlr.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND A high proportion of people in the United States at risk of unintended pregnancy also have limited primary care access. STUDY DESIGN We pooled data for analyses from separate 2015-2017 and 2017-2019 waves of the National Survey of Family Growth. Multivariable logistic regression was used to estimate associations between the usual source of health care and self-reported use of a comprehensive range of contraceptive options, as well as alignment between patient preference and the current method. RESULTS Compared with having a private doctor or Health Maintenance Organization, not having a usual source of care was associated with lower odds of using short-term hormonal methods (OR=0.54, 95% CI: 0.40-0.73, for an 11 percentage point lower rate); higher odds of using time-based methods (OR=1.47, 95% CI: 1.10-1.97, for a 6 percentage point higher rate); and higher odds of preferring a contraceptive method other than the one most recently used (OR=1.39, 95% CI: 1.01-1.90, for a 6 percentage point higher probability). Reliance on an emergency department as a usual source of care was not associated with contraceptive use or satisfaction with the method used. Reliance on urgent care was associated only with higher odds of using time-based methods (OR=1.60, 95% CI: 1.03-2.50, for a 7 percentage point higher rate). Clinic-based usual care was not associated with any differences in contraceptive use but was associated with preferring a contraceptive method other than the one most recently used (OR=1.65, 95% CI: 1.21-2.25, for an 8 percentage point higher probability). CONCLUSIONS All sources of usual care can improve contraceptive access.
Collapse
Affiliation(s)
- Rebecca Wells
- Department of Management, Policy, and Community Health, The University of Texas Health Science Center, Houston School of Public Health, Houston, TX
| | - Nicole K Smith
- Rural Institute for Inclusive Communities, University of Montana, Missoula, MT
| |
Collapse
|
4
|
Wells R, Smith NK, Rodriguez MI. Contraception Use by Title X Clients and Clients of Other Providers, 2015-2019. Womens Health Issues 2024; 34:59-65. [PMID: 37951782 DOI: 10.1016/j.whi.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 09/18/2023] [Accepted: 10/04/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Title X clinics provide access to a wide range of contraceptive options for individuals of all income levels and documentation statuses. As Title X continues to face political uncertainties, it is important to provide up-to-date information about its clients' use of contraception. This study used recent nationally representative data to compare contraception received by Title X clients with that received by clients of other providers. METHODS This article draws on 2015-2017 and 2017-2019 waves of the National Survey of Family Growth. The sample was restricted to 15- to 44-year-old women needing contraception. Logistic regressions estimated associations between receiving services at Title X clinics versus at other providers (including private) and use of a range of contraceptive options, as well as number of months' supply for those using oral contraceptives. RESULTS In 2015-2017, Title X was associated with using any contraception (adjusted odds ratio [AOR], 4.11; p = .004). In both waves, Title X clients were more likely to use long-acting reversible contraceptives (AOR, 1.78 in 2015-2017 [p = .023] and AOR, 2.59 in 2017-2019 [p = .003]) and hormonal methods other than oral contraceptives (AOR, 2.31 in 2015-2017 [p = .007] and AOR, 3.04 in 2017-2019 [p = .001]). In both waves, Title X clients using oral contraceptives were also more likely than non-Title X clients to receive more than a 3-month supply (AOR, 3.54 in 2015-2017 [p = .008] and AOR, 2.61 in 2017-2019 [p = .043]). Title X was not associated in either wave with use of barrier or time-based methods, such as periodic abstinence or withdrawal. CONCLUSIONS Patterns of contraceptive use by Title X clients compared with those of clients of other providers indicate that the Title X program has allowed access to a wide range of contraceptive methods. Ongoing research is necessary to see whether these patterns change over time.
Collapse
Affiliation(s)
- Rebecca Wells
- The University of Texas School of Public Health, Houston, Texas.
| | - Nicole K Smith
- Rural Institute for Inclusive Communities, University of Montana, Corbin Hall, Missoula, Montana
| | - Maria I Rodriguez
- Department of Obstetrics & Gynecology, Oregon Health & Health Science University, Portland, Oregon
| |
Collapse
|
5
|
Schulte A, Biggs MA. Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits. Womens Health Issues 2023; 33:573-581. [PMID: 37543443 DOI: 10.1016/j.whi.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/17/2023] [Accepted: 06/29/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics. METHODS Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects. RESULTS The analytic sample included 53,489 patient visits with reproductive-age (15-49 years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p = .02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p = .00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services. CONCLUSIONS Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.
Collapse
Affiliation(s)
- Alex Schulte
- Department of Health Policy, School of Public Health, University of California, Berkeley, Berkeley, California.
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland, California
| |
Collapse
|
6
|
Beatty K, Smith MG, de Jong J, Weber A, Adelli R, Khoury A. Impact of the Choose Well Initiative on Contraceptive Access at Federally Qualified Health Centers in South Carolina: A Midline Evaluation. Am J Public Health 2023; 113:1167-1172. [PMID: 37651659 PMCID: PMC10568501 DOI: 10.2105/ajph.2023.307384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Choose Well (CW) is a statewide contraceptive access initiative to reduce unintended pregnancy among patients utilizing federally funded family planning services. We examined CW's impact on contraceptive access at South Carolina federally qualified health centers from 2016 to 2019, which reported significantly higher increases in providing the full range of contraceptive methods and training onsite. CW prioritized ensuring change sustainability through obtaining funding and institutionalizing changes. (Am J Public Health. 2023;113(11):1167-1172. https://doi.org/10.2105/AJPH.2023.307384).
Collapse
Affiliation(s)
- Kate Beatty
- All authors are with the College of Public Health, East Tennessee State University, Johnson City
| | - Michael G Smith
- All authors are with the College of Public Health, East Tennessee State University, Johnson City
| | - Jordan de Jong
- All authors are with the College of Public Health, East Tennessee State University, Johnson City
| | - Amy Weber
- All authors are with the College of Public Health, East Tennessee State University, Johnson City
| | - Rakesh Adelli
- All authors are with the College of Public Health, East Tennessee State University, Johnson City
| | - Amal Khoury
- All authors are with the College of Public Health, East Tennessee State University, Johnson City
| |
Collapse
|
7
|
Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023. [DOI: 10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
Collapse
|
8
|
Swan LET. Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023; 40:5. [DOI: https:/doi.org/10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 06/22/2023]
Abstract
AbstractContraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.
Collapse
|
9
|
Madison AM, Powers D, Maslowsky J, Goyal V. Association Between Publicly Funded Contraceptive Services and the Abortion Rate in Texas, 2010-2015. Obstet Gynecol 2023; 141:361-370. [PMID: 36649327 PMCID: PMC9858333 DOI: 10.1097/aog.0000000000005057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/20/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate how the availability of contraceptive services was associated with a change in the abortion rate before and after Texas' legislative changes to the family planning budget in 2011 and abortion access in 2013. METHODS In this cross-sectional study, we obtained 2010 and 2015 data on contraceptive provision (number of publicly funded clinics and number of contraceptive clients served per 1,000 reproductive-aged women) from the Guttmacher Institute and county-level abortion data from the Texas Department of State Health Services. We categorized counties as having an abortion rate that increased or declined less than the national rate between 2010 and 2015 ( low-decline counties ) compared with those having an abortion rate that declined equal to or greater than the national rate between 2010 and 2015 ( high-decline counties ). We evaluated differences in contraceptive provision between high-decline and low-decline counties and evaluated county characteristics (racial and ethnic composition, unemployment, poverty, uninsured, education, distance to an abortion clinic, deliveries covered by Medicaid, and Catholic hospital marketplace dominance) as potential confounders. RESULTS Of 157 counties that had at least one contraceptive clinic in either 2010 or 2015, 49 were low-decline counties and 108 were high-decline counties. Although the total number of publicly funded family planning clinics increased by 10.8%, there was a 4.7% decrease in the total number of contraceptive clients served statewide. Compared with low-decline counties, high-decline counties had a higher median number of contraceptive clients served per 1,000 women aged 18-44 years (31.9 vs 60.7, P <.05) in 2015. Between 2010 and 2015, the abortion rate decreased 19.7% for each 1.0% increase in contraceptive clients served. CONCLUSION Texas counties with higher abortion-rate declines had more publicly funded contraceptive clinics and served more contraceptive clients than counties with lower declines, which may indicate the importance of greater access to publicly funded contraceptive services.
Collapse
Affiliation(s)
- Anita M Madison
- Department of Obstetrics and Gynecology, Louisiana State University Health Science Center, Baton Rouge, Louisiana; the Population Research Center, University of Texas at Austin, Austin, Texas; and the School of Public Health, University of Illinois Chicago, Chicago, Illinois
| | | | | | | |
Collapse
|
10
|
Effectiveness of training primary care internal medicine residents in etonogestrel implants and impact on their future practice: A cross-sectional study. Contraception 2022; 115:31-35. [PMID: 35917931 PMCID: PMC9994633 DOI: 10.1016/j.contraception.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the impact of an etonogestrel implant training program within a primary care Internal Medicine residency training program. STUDY DESIGN We surveyed graduates of our primary care Internal Medicine residency program in the Bronx, New York who performed implant procedures though the first 32 months after implementation of a monthly faculty-supervised resident implant clinic. We assessed the number of implants placed and removed per graduate, and surveyed graduates' satisfaction with the implant training program, perceived competence with implant procedures, and intent and ability to perform implant procedures and barriers to performing implant procedures postgraduation. RESULTS Between July 2017 and February 2020, 14 residents placed a total of 34 devices and removed four. All 14 program graduates completed the survey in August 2020. All but one respondent felt this training was valuable and 11 felt competent placing implants without supervision. Although 10 planned to provide implants following graduation, none have been able to, largely because of credentialing and clinic-practice level barriers. CONCLUSIONS The primary care Internal Medicine program graduates we surveyed (n = 14) valued our etonogestrel implant training program and perceived competence, particularly with implant placement. However, even those who intended to provide etonogestrel implants postgraduation were unable to do so. IMPLICATIONS Internal Medicine residents trained to place and remove etonogestrel implants are most comfortable with implant placement. However, these physicians may face barriers related to credentialing and ambulatory practice scope when attempting to provide this care in clinical practice.
Collapse
|
11
|
The Fracking Boom, Labor Structure, and Adolescent Fertility. POPULATION RESEARCH AND POLICY REVIEW 2022. [DOI: 10.1007/s11113-022-09722-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
12
|
Darney BG, Biel FM, Hoopes M, Rodriguez MI, Hatch B, Marino M, Templeton A, Oakley J, Schmidt T, Cottrell EK. Title X Improved Access To Most Effective And Moderately Effective Contraception In US Safety-Net Clinics, 2016-18. Health Aff (Millwood) 2022; 41:497-506. [PMID: 35377749 PMCID: PMC10033226 DOI: 10.1377/hlthaff.2021.01483] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Community health centers are a crucial source of health care for reproductive-age women. Some community health centers receive funding from the federal Title X program, which provides funding for family planning services for low-income women. We describe the provision of the most effective (intrauterine devices and implants) and moderately effective (short-acting hormonal methods) contraceptive methods in a large network of 384 community health center clinics across twenty states in 2016-18. Title X clinics provided more most and moderately effective contraception at all time points and for all age groups (adolescent, young adult, and adult). They provided 52 percent more of the most effective contraceptives to women at risk for pregnancy than clinics not funded by Title X. This finding was especially notable for adolescents (58 percent more). Title X clinics play a key role in access to effective contraception across the US safety net. Strengthening the Title X program should continue to be a policy priority for public health for the Biden-Harris administration.
Collapse
Affiliation(s)
- Blair G Darney
- Blair G. Darney , Oregon Health & Science University, Portland, Oregon
| | | | | | | | - Brigit Hatch
- Brigit Hatch, Oregon Health & Science University
| | | | | | | | | | | |
Collapse
|
13
|
Ventura LM, Beatty KE, Khoury AJ, Smith MG, Ariyo O, Slawson DL, Weber AJ. Contraceptive Access at Federally Qualified Health Centers During the South Carolina Choose Well Initiative: A Qualitative Analysis of Staff Perceptions and Experiences. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 2:608-620. [PMID: 35141709 PMCID: PMC8820399 DOI: 10.1089/whr.2021.0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 11/20/2022]
Abstract
Introduction: Federally qualified health centers (FQHCs) provide essential contraceptive services to low-income individuals; yet, access to all method options, notably intrauterine devices (IUDs) and implants, may be limited at non-Title X FQHCs. The South Carolina (SC) Choose Well initiative is a statewide contraceptive access initiative that was launched in 2017 and extends into 2022. Choose Well established a collaborative network between training and clinical partners and is aimed at facilitating implementation of contraceptive care best practices through capacity-building and training of clinical and administrative staff in partner organizations. The initiative provided funding for workforce expansion and contraceptive methods. We examined perceptions of staff from Choose Well-participating FQHCs regarding contraceptive access during the first 2 years of the initiative, including factors that facilitated or posed access challenges as well as sustaining factors. This study informs the process evaluation of Choose Well while providing data critical for uncovering and scaling up contraceptive access initiatives. Materials and Methods: Interviews were conducted with FQHC staff (n = 34) in 2018 and 2019 to assess Choose Well implementation and were recorded, transcribed, and double-coded via at least 80% interrater reliability or consensus coding. Data were analyzed according to clinical and administrative factors influencing contraceptive access. Results: Increased capacity for contraceptive counseling and provision through training and external funding for IUDs and implants were the most noted clinical factors facilitating access. Streamlining workflow processes was also a facilitator. Buy-in and engagement among staff and leadership emerged as a facilitator at some clinics and as a barrier at others. Policy/structural factors related to costs of devices and insurance coverage were identified as threats to sustainability. Conclusions: The Choose Well initiative contributed to the perception of an increase in contraceptive access at participating FQHCs in SC. Statewide contraceptive access initiatives have the potential to support FQHCs in meeting their clients' contraceptive needs. Organizational buy-in, sustainability of funding, and training are key to realizing the full potential of these initiatives.
Collapse
Affiliation(s)
- Liane M Ventura
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Kate E Beatty
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Amal J Khoury
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Michael G Smith
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Oluwatosin Ariyo
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Deborah L Slawson
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, Tennessee, USA
| | - Amy J Weber
- Department of Health Services Management and Policy, Center for Applied Research and Evaluation in Women's Health, East Tennessee State University, Johnson City, Tennessee, USA
| |
Collapse
|
14
|
Rodriguez MI, Skye M, Shokat M, Linz R, Pedhiwala N, Darney BG. Expanded Access to Postabortion Contraception under Oregon's Reproductive Health Equity Act. Womens Health Issues 2021; 32:20-25. [PMID: 34753627 DOI: 10.1016/j.whi.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 09/20/2021] [Accepted: 10/01/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We describe the first 24 months of expanded family planning services for low-income immigrants under Oregon's Reproductive Health Equity Act. We examined postabortion contraceptive use in rural versus urban locations. STUDY DESIGN We conducted a historical cohort study of abortion services reimbursed under Reproductive Health Equity Act in the first 2 years after its implementation (2018 and 2019). Our primary outcome was shift in contraceptive tier from a less effective method before an abortion to a more effective contraceptive method after an abortion. Our key independent variable was residence in a metropolitan or nonmetropolitan area. We tested the association of nonmetropolitan residence and shift to a tier 1 or tier 2 method after the abortion, controlling for other factors, using logistic regression. RESULTS Our analysis included 625 abortions from across the state. After an abortion, 66% of women transitioned to a more effective form of contraception. Nonmetropolitan residence was not significantly associated with a shift from no method or a tier 3 method to tier 1 or tier 2 method (adjusted odds ratio, 1.28; 95% confidence interval, 0.81-2.02) compared with metropolitan residence. CONCLUSIONS The program was successful in helping women not wishing pregnancy to transition to a more effective contraceptive method post abortion, regardless of metropolitan location of residence.
Collapse
Affiliation(s)
- Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon.
| | - Megan Skye
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Mitra Shokat
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon
| | - Rachel Linz
- Reproductive Health Program, Oregon Health Authority, Portland, Oregon
| | - Nisreen Pedhiwala
- Reproductive Health Program, Oregon Health Authority, Portland, Oregon
| | - Blair G Darney
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon; School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon
| |
Collapse
|
15
|
Rodriguez MI, Meath T, Huang J, Darney BG, McConnell KJ. Association of rural location and long acting reversible contraceptive use among Oregon Medicaid recipients. Contraception 2021; 104:571-576. [PMID: 34224694 DOI: 10.1016/j.contraception.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate whether the use of long-acting, reversible contraception (LARC) is equitably accessible to Medicaid recipients in rural and urban areas. We also determined whether women's health specialists' availability was associated with the type of LARC used. STUDY DESIGN We used claims data for 242,057 adult women who were continuously enrolled in Oregon Medicaid for at least one year and at risk of pregnancy from January 1, 2015, through December 31, 2017 to assess the association between LARC utilization and (1) rurality and (2) provider supply. Our primary analysis included 430,918 person-years. Regression models adjusted for patient age, whether the patient was newly eligible for Medicaid due to Medicaid expansion, and health status. We also examined differences in the caseload of implants and IUD by provider type (women's health specialist vs other). RESULTS Among all women, 11.6% had at least one claim indicating LARC use. There was no significant difference in overall LARC use by location (urban residence +0.66%, 95% CI [-0.12%, 1.43%]), although urban residents were slightly more likely to have an IUD (+0.72%, 95% CI [0.11%, 1.33%]). An increase of one women's health specialty provider per 10,000 women was associated with a 0.14 percentage point increase in the rate of IUD utilization (95% CI: 0.02, 0.26). Compared to other providers, women's health specialty providers supplied 62% of all IUDs and 43% of all implants. CONCLUSION Among Oregon's Medicaid enrollees, LARC is equitably used in rural areas; however, IUD use is slightly more frequent in urban areas.
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.
| | - Thomas Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Jiaming Huang
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| | - Blair G Darney
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States; OHSU-PSU School of Public Health, Portland, OR, United States; National Institute of Public Health (INSP), Center for Population Health (CISP). Cuernavaca, Morelos, Mexico
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States
| |
Collapse
|
16
|
Beatty KE, Smith MG, Khoury AJ, Zheng S, Ventura LM, Okwori G. Accessibility of federally funded family planning services in South Carolina and Alabama. Prev Med Rep 2021; 22:101343. [PMID: 33767947 PMCID: PMC7980054 DOI: 10.1016/j.pmedr.2021.101343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 02/12/2021] [Accepted: 02/20/2021] [Indexed: 11/23/2022] Open
Abstract
This study operationalized the five dimensions of health care access in the context of contraceptive service provision and used this framework to examine access to contraceptive care at health department (HD) (Title X funded) and federally qualified health center (FQHC) (primarily non-Title X funded) clinics in South Carolina and Alabama. A cross-sectional survey was conducted in 2017/18 that assessed clinic-level characteristics, policies, and practices related to contraceptive provision. Provision of different contraceptive methods was examined between clinic types. Survey items were mapped to the dimensions of access and internal consistency for each scale was tested with Cronbach's alpha. Scores of access were developed and differences by clinic type were evaluated with an independent t-test. The overall response rate was 68.3% and the sample included 235 clinics. HDs (96.9%) were significantly more likely to provide IUDs and/or Impants on-site than FQHCs (37.4%) (P < 0.0001). Scales with the highest consistency were Availability: Clinical Policy (24 items) (alpha = 0.892) and Acceptability (43 items) (alpha = 0.834). HDs had higher access scores than FQHCs for the Availability: Clinical Policy scale (0.58, 95% CL 0.55, 0.61) vs (0.29, 95% CL 0.25, 0.33) and Affordability: Administrative Policy scale (0.86, 95% CL 0.83, 0.90) vs (0.47, 95% CL 0.41, 0.53). FQHCs had higher access scores than HDs for Affordability: Insurance Policy (0.78, 95% CL 0.72, 0.84) vs (0.56, 95% CL 0.53, 0.59). These findings highlight strengths and gaps in contraceptive care access. Future studies must examine the impact of each dimension of access on clinic-level contraceptive utilization.
Collapse
Affiliation(s)
- Kate E Beatty
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, P.O. Box 70264, Johnson City, TN 37614, United States
| | - Michael G Smith
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, P.O. Box 70264, Johnson City, TN 37614, United States
| | - Amal J Khoury
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, P.O. Box 70264, Johnson City, TN 37614, United States
| | - Shimin Zheng
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, 149 Lamb Hall, P.O. Box 70259, Johnson City, TN 37614, United States
| | - Liane M Ventura
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, P.O. Box 70264, Johnson City, TN 37614, United States
| | - Glory Okwori
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, P.O. Box 70264, Johnson City, TN 37614, United States
| |
Collapse
|
17
|
Ariyo O, Khoury AJ, Smith MG, Leinaar E, Odebunmi OO, Slawson DL, Hale NL. From training to implementation: Improving contraceptive practices in South Carolina. Contraception 2021; 104:155-158. [PMID: 33894253 DOI: 10.1016/j.contraception.2021.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Capacity building and training to improve contraceptive care is essential for patient-centered care and reproductive autonomy. This study assessed the feasibility of translating the knowledge and skills gained from contraception trainings into improvements in practice. STUDY DESIGN Participants completed surveys following contraceptive care trainings provided to family planning clinic and hospital obstetric providers and staff as a part of the Choose Well contraceptive access initiative in South Carolina. Surveys assessed participants' intent to change their practice post-training and anticipated barriers to implementing change. A mixed-methods approach was utilized including descriptive analysis of Likert scale responses and thematic content analysis to synthesize open-ended, qualitative responses. RESULTS Data were collected from 160 contraceptive training sessions provided to 4814 clinical and administrative staff between 2017 and 2019. Post-training surveys were completed by 3464 participants (72%), and of these, 2978 answered questions related to the study outcomes. Most respondents (n = 2390; 80.7%) indicated intent to change their practice and 35.5% (n = 1044) anticipated barriers to implementing intended changes. Across all training categories, organizational factors (time constraints, policies and practices, infrastructure/resources) were the most frequently perceived barrier to improving contraceptive services. Structural factors related to cost for patients were also identified as barriers to IUD and implant provision. CONCLUSION The trainings were successful in influencing family planning staff and providers' intent to improve their contraceptive practices, yet some anticipated barriers in translating training into practice. Improvements in organizational and structural policies are critical to realizing the benefits of trainings in advancing quality contraceptive care. IMPLICATIONS In addition to training, coordinated efforts to address organizational practices and resources, coupled with system-level policy changes are essential to facilitate the delivery and sustainability of patient-centered contraceptive care.
Collapse
Affiliation(s)
- Oluwatosin Ariyo
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management and Policy, East Tennessee State University, Johnson City, TN, United States.
| | - Amal J Khoury
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management and Policy, East Tennessee State University, Johnson City, TN, United States
| | - Michael G Smith
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management and Policy, East Tennessee State University, Johnson City, TN, United States
| | - Edward Leinaar
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management and Policy, East Tennessee State University, Johnson City, TN, United States
| | - Olufeyisayo O Odebunmi
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management and Policy, East Tennessee State University, Johnson City, TN, United States
| | - Deborah L Slawson
- Department of Community and Behavioral Health, East Tennessee State University, Johnson City, TN, United States
| | - Nathan L Hale
- Center for Applied Research and Evaluation in Women's Health, Department of Health Services Management and Policy, East Tennessee State University, Johnson City, TN, United States
| |
Collapse
|
18
|
Harper CC, Comfort AB, Blum M, Rocca CH, McCulloch CE, Rao L, Shah N, Oquendo Del Toro H, Goodman S. Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care. Prev Med 2020; 141:106290. [PMID: 33096126 PMCID: PMC8032203 DOI: 10.1016/j.ypmed.2020.106290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.
Collapse
Affiliation(s)
- Cynthia C Harper
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America.
| | - Alison B Comfort
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Maya Blum
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Corinne H Rocca
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, United States of America
| | - Lavanya Rao
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America
| | - Nishant Shah
- Consultant, Bixby Center for Global Reproductive Health, University of California, San Francisco, School of Medicine, United States of America
| | - Helen Oquendo Del Toro
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, United States of America
| | - Suzan Goodman
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco School of Medicine, United States of America; Department of Family and Community Medicine, University of California, San Francisco School of Medicine, United States of America
| |
Collapse
|
19
|
Statz M, Evers K. Spatial barriers as moral failings: What rural distance can teach us about women's health and medical mistrust author names and affiliations. Health Place 2020; 64:102396. [PMID: 32739783 PMCID: PMC7391386 DOI: 10.1016/j.healthplace.2020.102396] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 11/15/2022]
Abstract
Policy attention to growing rural "health care deserts" tends to identify rural distance as a primary spatial barrier to accessing care. This paper brings together geography, health policy, and ethnographic methods to instead theorize distance as an expansive and illuminating concept that highlights place-based expertise. It specifically engages rural women's interpretations of rural distance as a multifaceted dimension of accessing health care, which includes but is not limited to women's health services and maternity care. Presenting qualitative research with 51 women in a rural region of the U.S., thematic findings reveal an interpretation of barriers to rural health care as moral failings rather than as purely spatial or operational challenges, along with wide communication of negative health care experiences owing to spatially-disparate but trusted social networks. Amid or owing to the rural crisis context, medical mistrust here emerges as a meaningful but largely unrecognized barrier to rural women's ability-and willingness-to obtain health care. This underscores how a novel interpretation of distance may inform policy efforts to address rural medical deserts.
Collapse
Affiliation(s)
- Michele Statz
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth Campus 1035 University Dr. Duluth, MN, 55812, USA.
| | - Kaylie Evers
- Medical Student University of Minnesota Medical School, Duluth Campus 1035 University Dr. Duluth, MN, 55812, USA.
| |
Collapse
|
20
|
Darney BG, Jacob RL, Hoopes M, Rodriguez MI, Hatch B, Marino M, Templeton A, Oakley J, Cottrell EK. Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers. JAMA Netw Open 2020; 3:e206874. [PMID: 32496568 PMCID: PMC7273194 DOI: 10.1001/jamanetworkopen.2020.6874] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/23/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Use of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net. Objective To evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception). Design, Setting, and Participants This was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states). Exposures Medicaid expansion status (by state). Main Outcomes and Measures Two National Quality Forum-endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception). Results The sample included 310 132 women from expansion states and 235 408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non-Title X clinics and nonexpansion states. Conclusions and Relevance In this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.
Collapse
Affiliation(s)
- Blair G. Darney
- Oregon Health & Science University, Portland, Oregon
- OHSU-PSU School of Public Health, Portland, Oregon
- National Institute of Public Health, Center for Population Health, Cuernavaca, Morelos, Mexico
| | | | | | | | - Brigit Hatch
- Oregon Health & Science University, Portland, Oregon
- OCHIN Inc, Portland, Oregon
| | - Miguel Marino
- Oregon Health & Science University, Portland, Oregon
- OHSU-PSU School of Public Health, Portland, Oregon
| | | | | | - Erika K. Cottrell
- Oregon Health & Science University, Portland, Oregon
- OCHIN Inc, Portland, Oregon
| |
Collapse
|
21
|
Liberty A, Yee K, Darney BG, Lopez-Defede A, Rodriguez MI. Coverage of immediate postpartum long-acting reversible contraception has improved birth intervals for at-risk populations. Am J Obstet Gynecol 2020; 222:S886.e1-S886.e9. [PMID: 31846612 DOI: 10.1016/j.ajog.2019.11.1282] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/12/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND In 2012, South Carolina revised the Medicaid policy to cover reimbursement for immediate postpartum long-acting reversible contraception. Immediate postpartum long-acting reversible contraception may improve health outcomes for populations at risk with a subsequent short-interval pregnancy. OBJECTIVES We examined the impact of the Medicaid policy change on the initiation of long-acting and reversible contraception (immediate postpartum and postpartum) within key populations. We determined whether immediate postpartum long-acting and reversible contraception use varied by adequate prenatal care (>7 visits), metropolitan location, and medical comorbidities. We also tested the association of immediate postpartum and postpartum long-acting, reversible contraception on interpregnancy interval of less than 18 months. STUDY DESIGN We conducted a historical cohort study of live births among Medicaid recipients in South Carolina between 2010 and 2017, 2 years before and 5 years after the policy change. We used birth certificate data linked with Medicaid claims. Our primary outcome was immediate postpartum long-acting and reversible contraception, and our secondary outcome was short interpregnancy interval. We characterize trends in long-acting and reversible contraception use and interpregnancy interval over the study period. We used logistic regression models to test the association of key factors (rural, inadequate prenatal care, and medical comorbidities) with immediate and outpatient postpartum long-acting and reversible contraception following the policy change and to test the association of immediate postpartum and postpartum long-acting and reversible contraception with short interpregnancy interval. RESULTS Our sample included 187,438 births to 145,973 women. Overall, 44.7% of the sample was white, with a mean age of 25.0 years. A majority of the sample (61.5%) was multiparous and resided in metropolitan areas (79.5%). The odds of receipt of immediate postpartum long-acting and reversible contraception use increased after the policy change (adjusted odds ratio, 1.39, 95% confidence interval, 1.34-1.43). Women with inadequate prenatal care (adjusted odds ratio, 1.50, 95% confidence interval, 1.31-1.71) and medically complex pregnancies had higher odds of receipt of immediate postpartum long-acting and reversible contraception following the policy change (adjusted odds ratio, 1.47, 95% confidence interval, 1.29-1.67) compared with women with adequate prenatal care and normal pregnancies. Women residing in rural areas were less likely to receive immediate postpartum long-acting and reversible contraception (adjusted odds ratio, 0.36, 95% confidence interval, 0.30-0.44) than women in metropolitan areas. Utilization of immediate postpartum long-acting and reversible contraception was associated with a decreased odds of a subsequent short interpregnancy interval (adjusted odds ratio, 0.62, 95% confidence interval, 0.44-0.89). CONCLUSION Women at risk of a subsequent pregnancy and complications (inadequate prenatal care and medical comorbidities) are more likely to receive immediate postpartum long-acting and reversible contraception following the policy change. Efforts are needed to improve access in rural areas.
Collapse
|
22
|
Amico JR, Heintz C, Bennett AH, Gold M. Access to IUD removal: Data from a mystery-caller study. Contraception 2020; 101:122-129. [DOI: 10.1016/j.contraception.2019.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/18/2019] [Accepted: 10/27/2019] [Indexed: 11/24/2022]
|
23
|
Cottrell E, Darney BG, Marino M, Templeton AR, Jacob L, Hoopes M, Rodriguez M, Hatch B. Study protocol: a mixed-methods study of women's healthcare in the safety net after Affordable Care Act implementation - EVERYWOMAN. Health Res Policy Syst 2019; 17:58. [PMID: 31186028 PMCID: PMC6558747 DOI: 10.1186/s12961-019-0445-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/29/2019] [Indexed: 11/29/2022] Open
Abstract
Background Evidence-based reproductive care reduces morbidity and mortality for women and their children, decreases health disparities and saves money. Community health centres (CHCs) are a key point of access to reproductive and primary care services for women who are publicly insured, uninsured or unable to pay for care. Women of reproductive age (15–44 years) comprise just of a quarter (26%) of the total CHC patient population, with higher than average proportions of women of colour, women with lower income and educational status and social challenges (e.g. housing). Such factors are associated with poorer reproductive health outcomes across contraceptive, preventive and pregnancy-related services. The Affordable Care Act (ACA) prioritised reproductive health as an essential component of women’s preventive services to counter these barriers and increase women’s access to care. In 2012, the United States Supreme Court ruled ACA implementation through Medicaid expansion as optional, creating a natural experiment to measure the ACA’s impact on women’s reproductive care delivery and health outcomes. Methods This paper describes a 5-year, mixed-methods study comparing women’s contraceptive, preventive, prenatal and postpartum care before and after ACA implementation and between Medicaid expansion and non-expansion states. Quantitative assessment will leverage electronic health record data from the ADVANCE Clinical Research Network, a network of over 130 CHCs in 24 states, to describe care and identify patient, practice and state-level factors associated with provision of recommended evidence-based care. Qualitative assessment will include patient, provider and practice level interviews to understand perceptions and utilisation of reproductive healthcare in CHC settings. Discussion To our knowledge, this will be the first study using patient level electronic health record data from multiple states to assess the impact of ACA implementation in conjunction with other practice and policy level factors such as Title X funding or 1115 Medicaid waivers. Findings will be relevant to policy and practice, informing efforts to enhance the provision of timely, evidence-based reproductive care, improve health outcomes and reduce disparities among women. Patient, provider and practice-level interviews will serve to contextualise our findings and develop subsequent studies and interventions to support women’s healthcare provision in CHC settings.
Collapse
Affiliation(s)
- Erika Cottrell
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America
| | - Blair G Darney
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
| | - Miguel Marino
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
| | - Anna Rose Templeton
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America.
| | - Lorie Jacob
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America
| | - Megan Hoopes
- OCHIN, Inc, 1881 SW Naito Pkwy, Portland, OR, 97201, United States of America
| | - Maria Rodriguez
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
| | - Brigit Hatch
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, United States of America
| |
Collapse
|
24
|
Satterwhite CL, French V, Allison M, Honderick T, Ramaswamy M. Access to contraception in local health departments, four Midwest states, 2017-2018. Contraception 2019; 99:363-367. [PMID: 30871935 PMCID: PMC6548685 DOI: 10.1016/j.contraception.2019.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Describe contraception availability at local health departments (LHDs) serving largely rural populations. STUDY DESIGN We invited administrators at LHDs located in four Midwest states to participate in an online survey conducted from September 2017-April 2018. We collected data on clinic staffing, patient population, receipt of Title X funds, and services provided to assess the proportion of LHDs providing any prescription method of contraception; secondary outcomes included healthcare staff training level and other reproductive health services provided. RESULTS Of 344 LHDs invited, 237 administrators completed the survey (68.9%). Three-quarters served rural populations. One-third (34.6%) provided short-acting hormonal contraception; however, availability varied by state (Kansas: 58.0%, 40/69; Missouri: 37.5%, 33/88; Nebraska: 16.7%, 3/18; Iowa: 9.7%, 6/62; p<.01). Only 8.4% of LHDs provided IUDs; 7.6% provided implants, and 5.9% provided both methods. LHDs in Nebraska and Kansas provided any long-acting method more frequently (Kansas: 17.4%, Nebraska: 16.7%, Iowa: 8.1%, Missouri: 4.6%; p=.04). LHDs receiving Title X funds (27.0%) were much more likely to provide any prescription contraception (85.1% vs. 14.2%, p<.01). Most LHDs relied on registered nurses (RNs) to provide medical care; 81.0% reported that RNs provided care≥20 days per month. Pregnancy testing was widely available in Missouri and Kansas (>87%) and less commonly available in Iowa and Nebraska (<18%) (p<.01). CONCLUSION LHDs in these states are currently ill-equipped to offer comprehensive contraceptive services. Women seeking care at LHDs have limited, if any, contraceptive options. IMPLICATIONS Local health departments in the Midwest, serving a largely rural population, rarely offer prescription contraception, especially long-acting reversible methods. Women residing in settings without broad access to publicly-funded healthcare providers may have limited access to comprehensive contraceptive services. Efforts to ensure rural access are needed.
Collapse
Affiliation(s)
- Catherine Lindsey Satterwhite
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160; University of Kansas School of Medicine, Department of Obstetrics and Gynecology, 3901 Rainbow Blvd, MS: 2028, Kansas City, KS 66160.
| | - Valerie French
- University of Kansas School of Medicine, Department of Obstetrics and Gynecology, 3901 Rainbow Blvd, MS: 2028, Kansas City, KS 66160.
| | - Molly Allison
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160.
| | - Tanya Honderick
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160.
| | - Megha Ramaswamy
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160.
| |
Collapse
|
25
|
Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services. Am J Prev Med 2018; 55:671-676. [PMID: 30342630 DOI: 10.1016/j.amepre.2018.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 07/13/2018] [Accepted: 07/19/2018] [Indexed: 11/20/2022]
|