Policy change is not enough: engaging provider champions on immediate postpartum contraception

Abstract

Rates of short-interval pregnancies that result in unintended pregnancies remain high in the United States and contribute to adverse reproductive health outcomes. Long-acting reversible contraception methods have annual failure rates of <1%, compared with 9% for oral contraceptive pills, and are an effective strategy to reduce unintended pregnancies. To increase access to long-acting reversible contraception in the immediate postpartum period, several State Medicaid programs, which include those in Iowa and Louisiana, recently established reimbursement policies to remove the barriers to reimbursement of immediate postpartum long-acting reversible contraception insertion. We used a mixed-methods approach to analyze 2013–2015 linked Medicaid and vital records data from both Iowa and Louisiana and to describe trends in immediate postpartum long-acting reversible contraception provision 1 year before and after the Medicaid reimbursement policy change. We also used data from key informant interviews with state program staff to understand how provider champions affected policy uptake. We found that the monthly average for the number of insertions in Iowa increased from 4.6 per month before the policy to 6.6 per month after the policy; in Louisiana, the average number of insertions increased from 2.6 per month before the policy to 45.2 per month. In both states, the majority of insertions occurred at 1 academic/teaching hospital. In Louisiana, the additional increase may be due to the engagement of a provider champion who worked at both the state and facility level. Recruiting, training, engaging, and supporting provider champions, as facilitators, with influence at state and facility levels, is an important component of a multipart strategy for increasing successful implementation of state-level Medicaid payment reform policies that allow reimbursement for immediate postpartum long-acting reversible contraception insertions.

The effects of CenteringPregnancy group prenatal care on postpartum visit attendance and contraception use

“…The relatively small differences and low rates in contraception outcomes suggest the limitations of prenatal care to support postpartum contraception choice. While South Carolina's Medicaid reimbursement policy supporting immediate postpartum LARCs went into effect in 2012, we expect adoption and implementation varied during the study period and by provider (this data was not available) [35,36]. Our preferential within-cluster matching approach controls statistically for provider differences.…”

Champions in context: which attributes matter for change efforts in healthcare?

“…As a case example for better understanding champions, we examined implementation of recommended immediate postpartum contraceptive services. Champions appear to play a powerful role in implementing this evidence-based practice [14][15][16]. Immediate postpartum contraception involves the insertion of a longacting reversible contraceptive (LARC; e.g., intrauterine device or contraceptive implant) during hospitalization for childbirth.…”

“…Immediate postpartum contraception involves the insertion of a longacting reversible contraceptive (LARC; e.g., intrauterine device or contraceptive implant) during hospitalization for childbirth. Although national guidelines recommend universal access to this service, it is provided almost exclusively at a small number of "early adopter" academic medical centers [14,17], and immediate postpartum LARC utilization remains rare [17,18]. Implementation is complex, requiring coordination across settings (e.g., outpatient and inpatient) and often siloed stakeholder groups (e.g., providers, pharmacy, and billing) [15,16].…”

Implementing a Learning Collaborative Framework for States Working to Improve Outcomes for Vulnerable Populations: The Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community

“…73 The successes of the earlier learning community offer a model for states to address complex public health issues requiring coordinated response across many sectors, agencies, and partners, a strength of a collaborative learning model. 69,71,74 The OMNI LC includes these components and requires multidisciplinary, multiagency state teams to participate in in-person meetings and virtual learning events 68 to implement systems change activities targeting OUD among pregnant and postpartum women and prenatal opioid exposure in infants. 67 To implement the OMNI LC, ASTHO partnered with a wide range of agencies and organizations, developed clear criteria for selecting states to participate in the activity, and identified core state team members critical for systems change.…”