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: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: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: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
Project description:OBJECTIVES:We investigated the prevalence of and sociodemographic associations with receiving prenatal and postpartum contraceptive counseling, including counseling on intrauterine devices (IUDs) and implants. METHODS:We used data from a prospective cohort study of 803 postpartum women in El Paso and Austin, Texas. We examined the prevalence of prenatal and postpartum counseling, provider discouragement of IUDs and implants, and associated sociodemographic characteristics using ?2 tests and logistic regression. RESULTS:One-half of participants had received any prenatal contraceptive counseling, and 13% and 37% received counseling on both IUDs and implants prenatally and postpartum, respectively. Women with more children were more likely to receive any contraceptive counseling prenatally (odds ratio [OR], 1.99; p < .01). Privately insured women (OR, 0.53; p < .05) had a lower odds of receiving prenatal counseling on IUDs and implants than publicly insured women. Higher education (OR, 2.16; p < .05) and attending a private practice (OR, 2.16; p < .05) were associated with receiving any postpartum counseling. Older age (OR, 0.61; p < .05) was negatively associated with receiving postpartum counseling about IUDs and implants and a family income of $10,000 to $19,000 (OR, 2.21; p < .01) was positively associated. Approximately 20% of women receiving prenatal counseling and 10% receiving postpartum counseling on IUDs and implants were discouraged from using them. The most common reason providers restricted use of these methods was inaccurate medical advice. CONCLUSIONS:Prenatal and postpartum counseling, particularly about IUDs and implants, was infrequent and varied by sociodemographics. Providers should implement evidence-based prenatal and postpartum contraceptive counseling to ensure women can make informed choices and access their preferred method of postpartum contraception.
| S-EPMC5694359 | 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:IntroductionLethal means safety counseling (LMSC) is an evidence-based suicide prevention intervention during which providers encourage patients to limit their access to lethal means (e.g., firearms, medications). Despite agreement about the importance of LMSC, it is underutilized in clinical practice.MethodsTo better understand the individual and contextual factors that influence LMSC and its implementation, we conducted a systematic review of qualitative studies examining stakeholder perceptions of the intervention. PubMed and PsycInfo were searched up to February 2021 using terms related to: (1) LMSC, firearms, or medications; (2) suicide, safety, or injury; and (3) qualitative methodology. Two coders used thematic synthesis to analyze findings from eligible papers, including developing a codebook and coding using an inductive and iterative approach (reliability k > 0.70). Confidence in review findings were evaluated using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach. Subthemes were assigned to domains in the Consolidated Framework for Implementation Research.FindingsOf the 19 papers identified, 18 discussed LMSC for firearms and 1 focused exclusively on LMSC for medications. The firearm-related studies explored perspectives of a variety of stakeholders (patients, providers, members of the firearms community, healthcare leaders, and family members) across multiple settings (emergency departments, pediatric and adult primary care, and outpatient mental health). Seven overarching themes emerged, including the: (1) importance of firearms to owners' identities and perceptions of ownership as a value and right, which can lead to perceived cultural tensions in clinical settings; (2) importance of patients understanding the context and rationale for LMSC; (3) value of providers showing cultural competency when discussing firearms; (4) influence of safety and risk beliefs on firearm behaviors; (5) need to navigate logistical concerns when implementing LMSC; (6) value of individualizing LMSC; (7) potential for trusted family members and friends to be involved in implementing LMSC.ConclusionThis synthesis of the qualitative literature informs clinical, operational, and research endeavors aimed at increasing the reach and effectiveness of LMSC. Future research should address the perspectives of individuals underrepresented in the literature (e.g., those from racial/ethnic minority groups) and further examine stakeholders' perceptions of LMSC for medication. [-2pt].Systematic review registration[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021237515], identifier [CRD42021237515].
| S-EPMC9634731 | biostudies-literature
Project description:Importance:The United States spends more money on medications than any other country. Most extended-release drugs have not consistently shown therapeutic or adherence superiority, and switching these medications to less expensive, generic, immediate-release formulations may offer an opportunity to reduce health care spending. Objective:To evaluate Medicare Part D and Medicaid spending on extended-release drug formulations and the potential savings associated with switching to generic immediate-release formulations. Design, Setting, and Participants:This cross-sectional study used the 2012 to 2017 Medicare Part D Drug Event and Medicaid Spending and Utilization data sets to analyze 20 extended-release drugs with 37 Medicare formulations and 36 Medicaid formulations. Only cardiovascular, diabetes, neurologic, and psychiatric extended-release drugs saving at most 1 additional daily dose compared with their immediate-release counterparts were included. Extended-release drugs with therapeutic superiority were excluded. Analyses were conducted from January to December 2019. Main Outcomes and Measures:Estimated Medicare Part D and Medicaid savings from switching extended-release to immediate-release drug formulations between 2012 and 2017. Results:Of the 6252 drugs screened for eligibility from the 2017 Medicaid Drug Utilization database and the 2017 Medicare Part D database, 67 drugs with extended-release formulations that were identified in the Medicare data set (20 distinct drugs with 37 formulations [19 brand, 18 generic]) were included in the analysis. In 2017, Medicare Part D spent $2.2 billion and Medicaid spent $952 million (a combined $3.1 billion) on 20 extended-release drugs. Between 2012 and 2017, Medicare Part D and Medicaid spent $12 billion and $5.9 billion, respectively, on extended-release formulations. Switching from brand-name to generic extended-release formulations was estimated to be associated with a $247 million reduction in Medicare spending and $299 million reduction in Medicaid spending in 2017, whereas switching all brand-name and generic extended-release formulations to immediate-release formulations in both Medicare and Medicaid was estimated to reduce spending by $2.6 billion ($1.8 billion for Medicare and $836 million for Medicaid) in 2017. During the study period, the estimated spending reduction associated with switching all patients receiving extended-release formulations (brand name extended-release and generic extended-release) to generic immediate-release formulations was $13.7 billion ($8.5 billion from Medicare and $5.2 billion from Medicaid). Conclusions and Relevance:The findings suggest that switching from extended-release drug formulations to therapeutically equivalent immediate-release formulations when available represents a potential option to reduce Medicare and Medicaid spending.
| S-EPMC7049080 | biostudies-literature