Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services.
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ABSTRACT:
SUBMITTER: Moniz MH
PROVIDER: S-EPMC8917096 | biostudies-literature | 2022 Mar
REPOSITORIES: biostudies-literature
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Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services.
Moniz Michelle H MH Dalton Vanessa K VK Smith Roger D RD Owens Lauren E LE Landis-Lewis Zach Z Peahl Alex F AF Van Kainen Barbara B Punch Margaret R MR Wetmore Marisa K MK Bonawitz Kirsten K Kolenic Giselle E GE Dehlendorf Christine C Heisler Michele M
American journal of obstetrics and gynecology 20211013 3
<h4>Background</h4>National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits-packages of resources and strategies to facilitate the implementati ...[more]
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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: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:BackgroundThere is unmet need for family planning in Rwanda. We previously developed an evidence-based couples' family planning counseling (C)FPC program in the capital city that combines: (1) fertility goal-based family planning counseling with a focus on long-acting reversible contraceptive (LARC) for couples wishing to delay pregnancy; (2) health center capacity building for provision of LARC methods, and (3) LARC promotion by community health workers (CHW) trained in community-based provision of oral and injectable contraception. From 2015 to 2016, this service was integrated into eight government health centers in Kigali, reaching 6072 clients and resulting in 5743 LARC insertions.MethodsFrom May to July 2016, we conducted cross-sectional health center needs assessments in 30 rural health centers using surveys, key informant interviews, logbook extraction, and structured observations. The assessment focused on the infrastructure, materials, and human resources needed for LARC demand creation and provision.ResultsFew nurses had received training in LARC insertion [41% implant, 27% intrauterine device (IUD)]. All health centers reported working with CHW, but none trained in LARC promotion. Health centers had limited numbers of IUDs (median 10), implants (median 39), functional gynecological exam tables (median 2), and lamps for viewing the cervix (median 0). Many did not have backup power supplies (40%). Most health centers reported no funding partners for family planning assistance (60%). Per national guidelines, couples' voluntary HIV counseling and testing (CVCT) was provided at the first antenatal visit at all clinics, reaching over 80% of pregnant women and their partners. However, only 10% of health centers had integrated family planning and HIV services.ConclusionsTo successfully implement (C)FPC and LARC services in rural health centers across Rwanda, material and human resource capacity for LARC provision will need to be greatly strengthened through equipment (gynecological exam tables, sterilization capacity, lamps, and backup power supplies), provider trainings and follow-up supervision, and new funding partnerships. Simultaneously, awareness of LARC methods will need to be increased among couples through education and promotion to ensure that demand and supply scale up together. The potential for integrating (C)FPC with ongoing CVCT in antenatal clinics is unique in Africa and should be pursued.
| S-EPMC8672509 | biostudies-literature
Project description: Not available
| S-EPMC7781163 | biostudies-literature
Project description:OBJECTIVE:Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use. STUDY DESIGN:We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3?months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. RESULTS:Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use. CONCLUSION:Integrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management. IMPLICATIONS:A model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.
| S-EPMC6941485 | biostudies-literature
Project description:IntroductionPrior longitudinal studies of long-acting reversible contraception (LARC) satisfaction and continuation guaranteed their participants access to LARC removal. Under real-world conditions, LARC users who wish to discontinue may experience barriers to LARC removal.MethodsA prospective cohort study recruited 1,700 postpartum Texans without private insurance from 8 hospitals in 6 cities. Our analysis included the 418 respondents who initiated LARC in the 24 months after childbirth. A content analysis of open-ended survey responses identified three categories of LARC users: satisfied, resigned, and dissatisfied. Satisfied LARC users were using their method of choice. Resigned users were using LARC as an alternative method when their preferred method was inaccessible. Dissatisfied users were unhappy with LARC. Multinomial logistic regression models identified risk factors for resignation and dissatisfaction. Cox proportional hazards models assessed differences in LARC discontinuation by satisfaction and sociodemographic characteristics.ResultsParticipants completed 1,505 surveys while using LARC. LARC users were satisfied in 83.46% of survey responses, resigned in 5.25%, and dissatisfied in 11.30%. Resignation was more likely if respondents were uninsured or wanted sterilization at the time of childbirth. The risk of dissatisfaction increased with time using LARC and was higher among uninsured respondents. U.S.-born Hispanic LARC users were more likely than foreign-born Hispanic LARC users to be dissatisfied and less likely to discontinue when dissatisfied. Dissatisfaction-but not resignation-predicted discontinuation. Cost, lack of insurance, and difficulty obtaining an appointment were frequent barriers to LARC removal.ConclusionsMost postpartum LARC users were satisfied, but users who wished to discontinue frequently encountered barriers.
| S-EPMC9283300 | biostudies-literature
Project description:ImportanceFacilitating access to the full range of contraceptive options is a health policy goal; however, inpatient provision of postpartum long-acting reversible contraceptive (LARC) methods has been limited due to lack of hospital reimbursement. Between March 2014 and January 2015, the Medicaid programs in 5 states began to reimburse hospitals for immediate postpartum LARC separately from the global maternity payment.ObjectiveTo examine the association between Medicaid policies and provision of immediate postpartum LARC, and to examine hospital characteristics associated with policy adoption.Design, setting, and participantsThis cross-sectional study used interrupted time series analysis. The setting was population-based in Georgia, Iowa, Maryland, New York, and Rhode Island. Participants included individuals who gave birth in these states between 2011 and 2017 (n = 3 097 188). Statistical analysis was performed from June 2021 to August 2022.ExposuresChildbirth after the start of Medicaid's reimbursement policy.Main outcomes and measuresImmediate postpartum LARC (outcome), teaching hospital, Catholic-owned or operated, obstetrical care level, and urban or rural location (hospital characteristics).ResultsThe study included a total of 1 521 491 births paid for by Medicaid and 1 575 697 paid for by a commercial payer between 2011 and 2017. Prior to Medicaid reimbursement changes, 489 389 of 726 805 births (67%) were to individuals between 18 and 29 years of age, 219 363 of 715 905 births (31%) were to non-Hispanic Black individuals, 227 639 of 715 905 births (32%) were to non-Hispanic White individuals, 155 298 of 715 905 births (22%) were to Hispanic individuals, and 113 605 of 715 905 births (16%) were to individuals from other non-Hispanic racial groups. Among Medicaid-paid births, the policies were associated with an increase in the rate of immediate postpartum LARC provision in all states, although results for Maryland were not consistent across sensitivity analyses. The change in trend ranged from a quarterly increase of 0.05 percentage points in Maryland (95% CI, 0.01-0.08 percentage points) and 0.05 percentage points in Iowa (95% CI, 0.00-0.11 percentage points) to 0.82 percentage points (95% CI, 0.73-0.91 percentage points) in Rhode Island. The policy was also associated with an increase in immediate postpartum LARC provision among commercially paid births in 4 of 5 states. After the policy, only 38 of 366 hospitals (10%) provided more than 1% of birthing people with immediate postpartum LARC. These adopting hospitals were less likely to be Catholic (0% [0 of 31] vs 17% [41 of 245]), less likely to be rural (10% [3 of 31] vs 33% [81 of 247]), more likely to have the highest level of obstetric care (71% [22 of 31] vs 29% [65 of 223]) and be teaching hospitals (87% [27 of 31] vs 43% [106 of 246]) compared with nonadopting hospitals.Conclusions and relevanceThis cross-sectional study's findings suggest that Medicaid policies that reimburse immediate postpartum LARC may increase access to this service; however, policy implementation has been uneven, resulting in unequal access.
| S-EPMC9587474 | biostudies-literature
Project description:ObjectivesTo examine recent rates of long-acting and permanent methods (LAPM) of contraception use during delivery hospitalization and correlates of their use.MethodsA retrospective cohort study utilizing the 2012-2016 National Inpatient Sample of hospitalizations in the United States of America. The International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes were used to identify deliveries, inpatient long-acting reversible contraception (IPP LARC), and postpartum tubal ligation (PPTL). We conducted univariable and multivariable logistic regression to examine associations between demographic, clinical, hospital and geographical characteristics with likelihood of LAPM including IPP LARC and PPTL.ResultsOur sample included 3,642,328 unweighted deliveries. The rate of IPP LARC increased from 34.6 to 54.9 per 10,000 deliveries (58.7%), while the rate of PPTL utilization decreased from 719.5 to 671.8 per 10,000 deliveries (6.6%) over the study period. In multivariable analysis of LAPM utilization versus neither, cesarean delivery (aOR 7.25, 95% CI 7.08-7.43) was associated with greater utilization. Native American (aOR 4.01, 95% CI 2.91-5.53) race was associated with increased use of IPP LARC compared to a non-long-acting method of contraception. Age between 18 and 29 years (aOR 6.21, 95% CI 5.42-7.11) was associated with greater use of IPP LARC versus PPTL. Delivering in a rural hospital ((aOR 0.09, 95% CI 0.06-0.12) and cesarean delivery (aOR 0.09, 95% CI 0.06-0.12) were associated with greater use PPTL versus IPP LARC.ConclusionsThe IPP LARC rate remains at less than 10% the PPTL rates in our study timeframe. The demonstrated variation in uptake of highly effective methods of contraception inpatient after delivery offer possible opportunities for better understanding and improvement in access.
| S-EPMC8449803 | biostudies-literature
Project description:IntroductionIn Uganda, although most women wish to delay or prevent future pregnancies, uptake of postpartum family planning (PPFP) is low. We explored behavioural factors influencing the utilisation of postpartum long-acting reversible contraceptives (LARCs) in Eastern Uganda.MethodsWe conducted a qualitative study in two districts of Eastern Uganda. We conducted 20 in-depth interviews and three focus group discussions with postpartum women, male partners, midwives, and village health team members. We analysed transcripts using framework analysis, based on the COM-B framework.ResultsThe use of immediate postpartum LARC was affected by the capabilities of women in terms of their knowledge and misconceptions. Limited capabilities of health workers to provide counselling and insert IUDs, as well as shortages of implants, reduced the physical opportunites for women to access PPFP. Social opportunities for women were limited because men wanted to be involved in the decision but rarely had time to accompany their partners to health facilities, and health workers often appeared too stressed. Men also feared that PPFP would enable their partners to be unfaithful. Motivation to take up immediate postpartum LARC included the desire to space births, preference for contraceptive implants over intra uterine devices (IUD) at the 6-week postpartum period, resumption of sex and menses, partner support, and perceived effectiveness of postpartum contraception. Participants thought that uptake of immediate postpartum LARC could be improved by health education and outreach visits, male involvement and couples' counselling in antenatal clinic appointments, and enabling switching between family planning methods (in case of side-effects) .ConclusionLow uptake of PPFP was caused by inadequate knowledge and misconceptions about LARC by women and their partners, insufficient numbers of midwives trained to provide PPFP, stock-outs of PPFP methods, and few social opportunities for couples to be counselled together. These factors could be addressed by scaling up effective, low cost and innovative ways to provide health education (such as films), involving men in decision-making, as well as training more midwives to provide PPFP services, and ensuring that they have sufficient time and supplies.
| S-EPMC11465926 | biostudies-literature
Project description:To increase access to long-acting contraception, we developed a reversible contraceptive microneedle patch that is simple-to-administer, slowly releases contraceptive hormone (levonorgestrel) for >1 month, and generates no biohazardous sharps waste. After manually pressing the patch to skin for 1 min, microneedles rapidly separate from the patch within the skin due to effervescence triggered by contact with skin's interstitial fluid, as demonstrated in rats and human participants. Long-acting contraception is achieved by formulating microneedles with a biodegradable polymer [poly(lactic-co-glycolic) acid] that slowly releases levonorgestrel for ~1 month in vitro. In rats, the patch maintained levonorgestrel concentration above the human contraceptive threshold level for >1 month, and a placebo microneedle patch was well-tolerated in human participants. Women of reproductive age in three continents demonstrated interest in and preference for long-acting contraception by microneedle patch. These studies indicate that an effervescent microneedle patch could facilitate greater access to long-acting contraception.
| S-EPMC6834388 | biostudies-literature