A qualitative analysis of Medicaid beneficiaries perceptions of prenatal and immediate postpartum contraception counseling
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ABSTRACT: Objectives:
In the United States, about four out of every ten births are financed by
SUBMITTER: Yates L
PROVIDER: S-EPMC9486062 | biostudies-literature | 2022 Jan
REPOSITORIES: biostudies-literature
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Project description:The period before pregnancy is critically important for the health of a woman and her infant, yet not all women have access to health insurance during this time. We evaluated whether increased access to health insurance under the Affordable Care Act Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and receipt of preconception health services. By comparing changes in outcomes for low-income women in expansion and nonexpansion states, we document greater preconception health counseling, prepregnancy folic acid intake, and postpartum use of effective birth control methods among low-income women associated with Medicaid expansion. We do not find evidence of changes on the other preconception health indicators examined. Our findings indicate that expanding Medicaid led to detectable improvements on a subset of preconception health measures.
| S-EPMC7688246 | biostudies-literature
Project description:In 2012 South Carolina's Medicaid program was the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (intrauterine devices and contraceptive implants) from its global maternity payment. Examining data on all Medicaid-insured South Carolina women giving birth from 2010 to 2014, we found that the new policy achieved its explicit goal: increasing the availability of immediate postpartum long-acting reversible contraception. Among adolescents, for whom most pregnancies are unintended, this represented new use of long-acting reversible options, rather than substitution for sterilization or for short-acting reversible methods. Therefore, the new policy also significantly increased use of highly effective postpartum contraception in an age group that is particularly vulnerable to closely spaced, higher-risk repeat pregnancies. However, fewer than half of facilities began to offer immediate postpartum long-acting reversible contraceptives after the policy change. Additional policy approaches may be needed to achieve widespread availability of this option.
| S-EPMC9555010 | biostudies-literature
Project description:IntroductionMedicaid expansion increased access to care, but longitudinal patterns of contraception use after the Medicaid expansion have not been described.MethodsWe evaluated the effects of Medicaid expansion on the amount and type of contraceptive prescriptions using the Medicaid State Utilization Dataset.ResultsOverall long-acting reversible contraception (LARC) use increased in both expansion and non-expansion states. In a difference-in-differences analysis, states that expanded Medicaid had no appreciable increase in per-capita prescription rates of LARC (p = 0.26) or short-acting hormonal contraception (p = 0.09) when compared to nonexpansion states.DiscussionThe Medicaid expansion was not associated with a change in per-capita LARC or short-acting hormonal contraception use.
| S-EPMC8011849 | biostudies-literature
Project description:ImportanceTogether, preterm birth and low birth weight are the second-leading cause of infant mortality in the US and occur disproportionately among Medicaid-paid births and among the infants of Black birthing persons. In 2012, South Carolina's Medicaid program began to reimburse hospitals for immediate postpartum long-acting reversible contraception (LARC) separately from the global maternity payment.ObjectiveTo examine the association between South Carolina's policy change and infant health.Design, setting, and participantsThis population-based cohort study using a difference-in-differences analysis included individuals with a South Carolina Medicaid-paid childbirth between January 2009 and December 2015. Data were analyzed from December 2020 to July 2021.ExposuresMedicaid-paid childbirth after March 2012 in South Carolina hospitals that had implemented the policy.Main outcomes and measuresImmediate postpartum LARC uptake, subsequent birth within 4 years, subsequent short-interval birth, days to subsequent birth, subsequent preterm, and low-birth-weight birth within 4 years.ResultsThe study sample included 186 953 Medicaid-paid births between January 2009 and December 2015 in South Carolina (81 110 births from 2009 to 2011, 105 843 births from 2012 to 2015, and 46 414 births in exposure hospitals). The policy was associated with an absolute 5.6-percentage point (95% CI, 3.7-7.4) increase in the probability of receiving an immediate postpartum LARC overall, with significantly larger effects for non-Hispanic Black individuals than non-Hispanic White individuals (difference in coefficients 3.54; 95% CI, 1.35-5.73; P = .002). The policy was associated with a 0.4-percentage point (95% CI, -0.7 to -0.1) decrease in the probability of subsequent preterm birth and a 0.3-percentage point (95% CI, -0.7 to 0) decrease in the probability of subsequent low birth weight. No significant difference in the association between the policy and preterm birth or low-birth-weight birth between non-Hispanic Black and non-Hispanic White individuals was found. The policy was associated with a 0.6-percentage point (95% CI, -1.2 to -0.1) decrease in the probability of short-interval birth and a 27-day (95% CI, 11-44) increase in days to next birth among non-Hispanic Black individuals. The policy was associated with a significant decrease in the probability of a subsequent birth overall; however, confidence in this result is attenuated somewhat by nonparallel trends for this outcome before the policy change.Conclusions and relevanceFindings of this cohort study suggest policies increasing access to immediate postpartum LARC may improve birth outcomes but should be accompanied by other policy efforts to reduce inequity in these outcomes.
| S-EPMC8749696 | biostudies-literature
Project description:BackgroundImmediate postpartum long-acting reversible contraception (LARC) is an evidence-based practice, but hospitals face significant barriers to its adoption. Our objective was to examine how organizational context (e.g., size, employee attitudes toward the clinical practice) and implementation strategies (i.e., the actions taken to routinize a clinical practice) drive successful implementation of immediate postpartum LARC services, with a goal of informing the design of future implementation interventions.MethodsWe conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 US maternity hospitals. In 2017-2018, we conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research. Qualitative measures of implementation success included stakeholder satisfaction, routinization, and sustainability of immediate postpartum LARC services. Qualitative content analysis and cross-case synthesis explored relationships among organizational context, implementation strategies, and implementation success.ResultsWe completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. Successful implementation required three essential conditions: effective implementation champions, an enabling financial environment, and hospital administrator engagement. Six other contextual conditions were influential: trust and effective communication, alignment with stakeholders' professional values, perception of meeting patients' needs, robust learning climate, compatibility with workflow, and positive attitudes and adequate knowledge about the clinical practice. On average, sites used 18 (range 11-22) strategies. Strategies to optimize the financial environment and train clinicians and staff were commonly used. Strategies to plan and evaluate implementation and to engage patients emerged as promising to address barriers to practice change, yet were often underused.ConclusionsImplementation efforts in maternity settings may be more successful if they select strategies to optimize local conditions for success. Our findings elucidate key contextual conditions to target and provide a menu of promising implementation strategies for incorporating recommended contraceptive services into routine maternity practice. Additional prospective research should evaluate whether these strategies effectively optimize local conditions for successful implementation in a variety of settings.
| S-EPMC8042857 | biostudies-literature
Project description:ObjectivesWe evaluated the effect of immediate postpartum use of depot medroxyprogesterone acetate (DMPA) on the timing of lactogenesis stage II (LS-II).Study designThe initial design randomly assigned adults who delivered a full-term infant in 2019-2021 to receive within 48 hours of delivery: (1) DMPA, (2) placebo injection, or (3) no injection. Due to low enrollment, we changed in 2021-2023 to a nonrandomized design using matching at recruitment for obesity and delivery method and propensity score weighting for analysis. We combined data from both designs to compare immediate postpartum DMPA use (N = 55) vs control (placebo or no injection) group (N = 95). We defined noninferiority a priori as being met if the upper bound of a two-sided 95% CI for mean difference in time to LS-II between groups was <6 hours.ResultsThe unweighted mean time to LS-II was 57.8 hours in the DMPA group (SD, 29.4) and 64.1 hours in the control group (SD, 36.1). Using propensity score weighting to make the groups comparable with respect to age, race, delivery method, and previous live births, the mean time to LS-II was 5.5 hours shorter (95% CI, -16.4, 5.5) for women in the DMPA relative to control group.ConclusionsWe found no evidence that DMPA use inhibits the onset of LS-II. Findings support immediate postpartum DMPA initiation among those intending to engage in human milk feeding.ImplicationsA controlled trial (N = 150) did not detect any difference in time to lactogenesis stage II ("milk let-down") between injectable contraception use within the first 48 hours postpartum and those without this exposure.
| S-EPMC11725434 | biostudies-literature
Project description:ObjectiveWe aimed to evaluate the impact of an antenatal group healthy relationship education program on the postpartum use of long-acting reversible contraception (LARC).Materials and methodsThis is a planned subgroup analysis of a larger randomized controlled trial. Pregnant and newly parenting women were randomized to either group healthy relationship education, "MotherWise," or no additional services. An evidence-based healthy relationship education program and individual case management sessions were provided. The program did not include any prenatal care or contraception counseling. This subgroup analysis included those participants with a nonanomalous gestation randomized at <40 weeks who received care and delivered at a single safety-net hospital and were discharged home with a live infant(s).ResultsFrom September 2, 2016 to December 21, 2018, 953 women were randomized in the larger trial; 507 met inclusion criteria for this study; 278 randomized to program and 229 controls. Participants were mostly young, parous, Hispanic, publicly insured women. Participants randomized to program were more likely to take a prescription medicine and be delivered through cesarean; there were not any other significant differences in baseline, antenatal, or perinatal outcomes. Those randomized to program were more likely to be discharged home with immediate postpartum LARC in place (odds ratio [OR] 1.87; confidence interval [CI] 1.17-3.00), and more likely to be using LARC at the postpartum visit (OR 2.19; CI 1.34-3.56).ConclusionAntenatal group healthy relationship education provided separately from prenatal care is associated with a twofold increase in the use of postpartum LARC.Clinical trial registrationClinicalTrials.gov NCT02792309; https://clinicaltrials.gov/ct2/show/NCT02792309?term=NCT02792309&draw=2&rank=1.
| S-EPMC10061321 | biostudies-literature
Project description:ObjectiveAfrican American and Hispanic women with systemic lupus erythematosus (SLE) have the highest rates of potentially avoidable pregnancy complications, yet racial disparities in family planning among reproductive-age women with SLE have not been well-studied. Our objective was to examine whether there are racial differences in contraception encounters and dispensing among US Medicaid-insured women with SLE.MethodsUsing Medicaid claims data from 2000-2010, we identified women ages 18-50 years with SLE. We examined contraception encounters and uptake over 24 months. We used multivariable logistic regression to estimate the odds ratio and 95% confidence interval by race/ethnicity of contraception encounters, any contraception dispensing, and highly effective contraception (HEC) use, adjusted for age, region, year, SLE severity, and contraindication to estrogen. We also compared contraception encounters and dispensing among women with SLE to the general population and women with diabetes mellitus.ResultsWe identified 24,693 reproductive-age women with SLE; 43% were African American, 35% White, 15% Hispanic, 4% Asian, 2% other race, and 1% American Indian/Alaska Native. Nine percent had a contraceptive visit, 10% received any contraception, and 2% received HEC. Compared to White women, African American and Asian women had lower odds of contraception dispensing, and African American women had lower odds of HEC use. Women with SLE were more likely to receive HEC than the general population and women with diabetes mellitus.ConclusionIn this study of reproductive-age women with SLE, African American and Asian women had lower odds of contraception dispensing and African American women had lower odds of HEC use. Further study is needed to understand the factors driving these racial disparities among this population.
| S-EPMC7728620 | biostudies-literature
Project description: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.
| S-EPMC5924570 | biostudies-literature
Project description:ObjectivesTo compare receipt of contraception and method effectiveness in the early postpartum period among women with and without a recent preterm birth (PTB).MethodsWe used data from North Carolina birth certificates linked to Medicaid claims. We assessed contraceptive claims with dates of service within 90 days of delivery among a retrospective cohort of women who had a live birth covered by Medicaid between September 2011 and 2012 (n = 58,201). To estimate the odds of receipt of contraception by PTB status (24-36 weeks compared to 37-42 weeks [referent]), we used logistic regression and tested for interaction by parity. To estimate the relationship between PTB and method effectiveness based on the Center for Disease Control and Prevention Levels of Effectiveness of Family Planning Methods (most, moderate and least effective [referent]), we used multinomial logistic regression.ResultsLess than half of all women with a live birth covered by Medicaid in North Carolina had a contraceptive claim within 90 days postpartum. Women with a recent PTB had a lower prevalence of contraceptive receipt compared to women with a term birth (45.7% vs. 49.6%). Women who experienced a PTB had a lower odds of receiving contraception. When we stratified by parity, women with a PTB had a lower odds of contraceptive receipt among women with more than two births (0.79, 95% CI 0.74-0.85), but not among women with two births or fewer. One-fourth of women received a most effective method. Women with a preterm birth had a lower odds of receiving a most effective method (0.83, 95% CI 0.77-0.88) compared to women with a term birth.Conclusions for practiceContraceptive receipt was low among women with a live birth covered by Medicaid in North Carolina. To optimize contraceptive use among women at risk for subsequent preterm birth, family planning strategies that are responsive to women's priorities and context, including a history of preterm birth, are needed.SignificanceAccess to free or affordable highly effective contraception is associated with reductions in preterm birth. Self-report data indicate that women with a very preterm birth (PTB) are less likely to use highly or moderately effective contraception postpartum compared to women delivering at later gestational ages. Using Medicaid claims data, we found that less than half of all women with a Medicaid covered delivery in North Carolina in 2011-2012 had a contraceptive claim within 90 days postpartum, and one fourth received a most effective method. Women with a PTB and more than two children were least likely to receive any method. Family planning strategies that are responsive to women's priorities and context, including a history of preterm birth, are needed so that women may access their contraceptive method of choice in the postpartum period.
| S-EPMC7176545 | biostudies-literature