Statewide Contraceptive Access Initiatives: A Critical Perspective

Long-Acting Reversible Contraception (LARC) and Early Childbearing Revisited: Births and Birth Intendedness After LARC Removal in a State Medicaid Population (2012-2020)

Objectives. To analyze births and birth intendedness after long-acting reversible contraception (LARC) removal among Medicaid-insured women. Methods. We linked all Delaware women with a Medicaid-covered LARC removal in 2012 to 2020 (n = 8047) to birth records and to Pregnancy Risk Assessment Monitoring System (PRAMS) pregnancy intendedness survey responses (n = 241). Results. Births within 3 years of a Medicaid-covered LARC removal were much more likely to be to women in their 20s compared with all Medicaid births (63.5% vs 53.4%; P < .001). The intended proportion for births within 3 years of Medicaid-covered LARC removal (65.2%) was higher than for all Medicaid-covered births (58.8%; P = .08) and was consistently above 60% across all age groups younger than 30 years. Conclusions. A state Medicaid-insured population's use of highly effective reversible contraception was associated with births being concentrated among women in their 20s and with consistently high fractions of intended births across younger ages at birth. Public Health Implications. Programs and policies may consider LARC access for its potential to increase low-income women's reproductive autonomy by enhancing their ability to achieve births at the age of their choosing. (Am J Public Health. Published online ahead of print October 10, 2024:e1-e8. https://doi.org/10.2105/AJPH.2024.307844).

Decomposition analysis of racial and ethnic differences in receipt of immediate postpartum, long-acting, reversible, and permanent contraception

OBJECTIVES

This study aimed to determine the factors contributing to racial and ethnic disparities in the use of immediate postpartum, long-acting reversible contraception (IPP LARC) and permanent contraception among Medicaid recipients.

STUDY DESIGN

We conducted a cross-sectional study using 3 years of national Medicaid claims data to examine the rates of IPP LARC use alone and a composite measure of postpartum permanent contraception and IPP LARC within 7 days of delivery by race and ethnicity. We used a Blinder-Oaxaca model to quantify the extent to which medical complexity, age, rurality, mode of delivery, and year explained differences in outcomes among different minoritized groups in comparison to non-Hispanic White women.

RESULTS

Our study sample contained 1,729,663 deliveries occurring from 2016 through 2018 among 1,605,199 people living in 16 states. IPP LARC use rates were highest among Black (2.2%), followed by American Indian and Alaska Native at 2.1% and Hawaiian/Pacific Islander beneficiaries at 1.9%, Hispanic (all races) at 1.2%, and Asian at 1.0%. IPP LARC was lowest among White beneficiaries (0.8%). Medical complexity, age, rurality, year, and mode of delivery explained only 12.3% of the difference in IPP LARC rates between Black and White beneficiaries. Postpartum permanent contraception was highest among White (7.6%), Hispanic (7.2%), and American Indian and Alaska Native (6.8%), followed by Black (6.3%), Hawaiian/Pacific Islander (5.1%) and lowest among Asian women (4.1%). When we examined the use of IPP LARC or postpartum permanent contraception together, these same factors explained 94.4% of the differences between Black and White beneficiaries.

CONCLUSIONS

While differences in the use of IPP LARC by race and ethnicity were identified, our findings suggest that overall use of inpatient highly effective contraception are similar across racial and ethnic groups.

IMPLICATIONS

When IPP LARC and postpartum permanent contraception are examined jointly, their use is similar across racial and ethnic groups.

Postpartum long-acting reversible contraceptive adoption after a statewide initiative

OBJECTIVES

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

DATA SOURCES AND STUDY SETTING

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

STUDY DESIGN

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

DATA COLLECTION/EXTRACTION METHODS

Data were extracted from administrative claims.

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

Patient Barriers to Discontinuing Long-Acting Reversible Contraception

OBJECTIVES

To describe how frequently a national sample of patients with experience discontinuing or desiring discontinuation of long-acting reversible contraception (LARC) experienced barriers to discontinuation.

METHODS

We conducted an online survey of individuals ages 18 to 50 in the United States who had previously used and discontinued or attempted to discontinue LARC. We recruited respondents using the Amazon platform MTurk. Respondents provided demographic information and answered questions regarding their experience discontinuing LARC, including reasons removal was deferred or denied. We analyzed frequency of types of barriers encountered and compared these by demographic factors.

RESULTS

Of the 376 surveys analyzed, 99 (26%) described experiencing at least one barrier to removal. Barriers were disproportionately reported by those who had public health insurance, a history of abortion, and a history of birth compared to those who did not report barriers to removal. They also more frequently identified as Latinx, Asian, or Middle Eastern. Most barriers were provider-driven and potentially modifiable.

CONCLUSIONS FOR PRACTICE

Barriers to LARC discontinuation are common and may be provider- or systems-driven. Providers should be mindful of biases in their counseling and practices to avoid contributing to these barriers.

Challenges accessing contraceptive care and interest in over-the-counter oral contraceptive pill use among Black, Indigenous, and people of color: An online cross-sectional survey

OBJECTIVE

To examine challenges accessing contraception in the past year and their association with interest in using an over the counter (OTC) oral contraceptive pill (OCP) among Black, Indigenous, and people of color (BIPOC) in the United States.

STUDY DESIGN

From May 2021 to March 2022, a collaborative research team conducted a cross-sectional online survey using convenience sampling to recruit people who identify as Asian American, Native Hawaiian, or Pacific Islander, Black or African American, Indigenous, or Latina/Latinx and used or wanted to use a contraceptive method in the past year. Respondents were recruited through reproductive justice and community-based organizations.

RESULTS

Among 727 respondents, 45% reported experiencing at least one challenge accessing contraception in the past year of which 37% reported a logistical challenge, and 20% reported an interpersonal challenge. Sixty-seven percent of respondents said they were likely to use an OTC OCP. Respondents who reported experiencing at least one challenge accessing contraception in the past year were more likely to say they would use an OTC OCP. Fifty-seven percent of respondents who were not using a contraceptive method in the past year reported they were likely to use an OTC OCP.

CONCLUSION

Among people in this study, interest in an OTC OCP is high, particularly among those who have faced challenges accessing contraception, and among those who are not currently using a contraceptive method.

IMPLICATIONS

Availability of an OCP OTC has the potential to address challenges accessing contraceptive care among BIPOC in the United States, who are often impacted by structural inequities and racism. Findings from this study can inform future OTC implementation strategies to ensure OTC access addresses logistical and interpersonal challenges.

Same-day long-acting reversible contraceptive utilization after a statewide contraceptive access initiative

BACKGROUND

Same-day placement of long-acting reversible contraceptives, occurring when the device is requested and placed within a single visit, reduces barriers to the patient and reduces unintended pregnancies. Despite the safety and efficacy of same-day placement, access to same-day services remains low.

OBJECTIVE

This study aimed to evaluate the effects of the Delaware Contraceptive Access Now initiative, a statewide initiative in Delaware focused on increasing same-day access to effective contraception on same-day receipt of long-acting reversible contraceptives.

STUDY DESIGN

We used Medicaid claims and encounter data to identify instances of same-day and multivisit receipts of long-acting reversible contraceptives among Medicaid-enrolled individuals in Delaware and Maryland aged 15-44 years who were covered in a full-benefits or family planning Medicaid aid category during the month of the placement and the 2 previous months. We used a difference-in-differences design that compared changes in the outcome from before to after implementation of the initiative among placements at agencies that participated in the initiative (n=6676) vs 2 alternative comparison groups: placements at Delaware agencies that did not participate (n=688) and placements in Maryland (n=35,847).

RESULTS

We found that the intervention was associated with a 13.3 percentage point increase (95% confidence interval, 1.9%-24.7%) in receipt of same-day long-acting reversible contraceptives using a nonparticipating Delaware comparison group, a 21.1 percentage point increase (95% confidence interval, 13.7%-28.6%) using a Maryland comparison group, and a 21.0 percentage point increase (95% confidence interval, 14.1%-27.9%) using a pooled comparison group. The effects were larger for implants than intrauterine devices.

CONCLUSION

The Delaware Contraceptive Access Now initiative substantially increased the number of patients receiving long-acting reversible contraceptives through a single-visit encounter. Our findings suggested that coordinated interventions involving provider and staff training and capital investments that seed device stocking can increase the number of patients receiving same-day long-acting reversible contraceptives.