By Melinda Young
Rural patients were less likely to have access to immediate postpartum long-acting reversible contraception (LARC) even six years after Pennsylvania Medicaid changed policy to provide a way for providers to receive fair reimbursement for the procedure, new research finds.1
“We took an interest in this because there is pretty good evidence, clinically, for offering LARC and IUDs [intrauterine devices] at the same hospitalization as delivery of their baby,” says Sarah Horvath, MD, MSHP, FACOG, an associate professor of obstetrics and department vice chair for research at Penn State University Hershey Medical Center in Hershey, PA. “We have great evidence this should be offered to patients,” she adds.
The benefits of immediate postpartum LARC are that the patient clearly is not pregnant and would be saved the time and trouble of a return office visit. “This is really a great thing to offer for folks who do not have transportation,” Horvath notes.
Immediate postpartum LARC is recommended by the American College of Obstetricians and Gynecologists. Research shows it is beneficial to patients. The only drawbacks are the logistical issues, including stocking LARC and getting payers on board with it. “It’s super complicated,” Horvath explains. “It requires the clinician who is doing the delivery to be comfortable and trained to do it, and you also have to figure out how to have it stocked in your hospital.”
Payment also is problematic. Insurance companies tend to bundle payment for labor and delivery, and if a provider provides an implant or IUD immediately after delivery, this cost is not covered as an extra procedure/device, she says. “The hospital is paid a set amount for the hospital delivery, but [they] won’t get reimbursed any more for LARC,” she adds. “How many hospitals are going to give you that device? They won’t. So, the insurance piece of this has always been part of the problem.”
The solution to the payment piece was for states to create separate billing through Medicaid for immediate postpartum LARC. “What people found was, if they could get Medicaid to pay for this care outside of the delivery bundle, then hospitals will be on board and start to offer it,” Horvath says. Pennsylvania made this change in 2016, following other states’ example. While this benefits Medicaid patients directly, it can have an indirect benefit for people with private insurance because those companies usually follow Medicaid in their coverage changes, she adds.
“If you have Medicaid in Pennsylvania — as of 2016, your immediate postpartum LARC will be covered outside of the maternal bundle,” Horvath says. “If you have private insurance, it’s still patchwork [coverage].” Some payers will say they will cover LARC at the six-week postpartum visit instead of when it is provided after childbirth.
“Our question was, ‘Is it enough for Medicaid to cover it? Will that make hospitals implement the care?’ This was the theory that everyone was putting out there,” Horvath says. “Pennsylvania is a nice, heterogenous state and there is good enough state-level data.”
So, Horvath and co-investigators sought an answer to the question of whether Medicaid’s policy change did what they anticipated in making immediate postpartum LARC available to all eligible for Medicaid coverage. “The answer is yes and no,” Horvath says. “Yes, it did increase access. Before the policy change, we had four hospitals doing implants, and one of the four was doing IUDs, and that was it.” Six years later, almost half of hospitals offer LARC immediately after childbirth. “It’s a big increase, but not close to enough,” she says.
Since an access problem still exists, researchers’ next study looks at why more or all hospitals are not offering this postpartum contraceptive service. It is not yet published but raises some interesting points. “It turns out, it is the people with the least access to all kinds of care who still have the least access to this care,” Horvath says. “If you live in a rural location, bigger hospitals have implemented it; there are more deliveries happening at those locations.”
In urban areas, 61% of patients have access to immediate postpartum LARC; in rural areas, only 45.4% of patients have access.1 “What’s interesting is these are folks who are traveling the farthest and have the biggest access issues in trying to get their care,” she says. “It will be that much harder for them to get back for their postpartum visit, and they may not have access to implants and IUDs in their community.”
The roadblock to universal immediate postpartum LARC for people on Medicaid is with the providers. Hospitals that allow LARC after childbirth typically have a clinical champion and a sense of meeting patient needs. They also have adequate knowledge about immediate postpartum LARC.1
A big help to implementing postpartum LARC is the Perinatal Quality Collaborative (PQC) initiative. The PQC is part of the Pennsylvania maternal mortality review committee, and it gives support to hospitals through initiatives that target state-level drivers of maternal morbidity and mortality.1 The PQC developed a comprehensive immediate postpartum LARC initiative with the goals of improving patient access to contraception and increasing birth intervals.1 Investigators found that the most frequently identified external support program was the Pennsylvania PQC, especially for rural hospitals.1
OB/GYNs and other providers in other states could advocate for their state’s maternal morbidity review committee to form a PQC that could help improve immediate postpartum contraception access. PQCs can provide a toolkit and support materials that are helpful to physicians and hospitals, Horvath says.
Another way to increase access is for hospitals to advocate for private insurance coverage of LARC outside of the maternity care bundle, she adds. “When we did interviews, we found that there was a reverse inequity, where it was really easy to do immediate postpartum LARC for patients who had Medicaid and — ironically — really hard to do for patients who had private insurance,” Horvath explains. “It never feels good when you are providing different care for people based on their insurance status.”
“At our hospital, we now have implemented immediate postpartum LARC at the time of delivery,” she says. “I tell residents to start the conversation by 28 weeks [gestation].”
Providers can tell patients what their contraceptive options are and find out which option sounds good for them. If they say they would like an implant or IUD, then the provider may suggest they consider getting it at the time of delivery or at their six-week postpartum visit, Horvath says. If they say they would like immediate postpartum LARC, then that is written on their chart, and the hospital will have their contraceptive ready for them, she adds.
“If they don’t want it at the time of delivery, then we ask them before they leave the hospital if they want it at the six-week visit, so we can [prepare],” Horvath explains. “We do everything we can to help, but there are still people who fall through the cracks.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
Reference
1. Horvath S, Guare EG, Ferguson G, Chuang CH. Pennsylvania Medicaid policy and rural hospital implementation of immediate postpartum contraception. Contraception. 2025; Feb 27:110858. doi: 10.1016/j.contraception.2025.110858. [Online ahead of print].
Rural patients were less likely to have access to immediate postpartum long-acting reversible contraception (LARC) even six years after Pennsylvania Medicaid changed policy to provide a way for providers to receive fair reimbursement for the procedure, new research finds.
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