States and providers can improve access through policies, programs
By Melinda Young
Long-acting reversible contraception (LARC) barriers include its higher cost and the need for in-clinic/office insertion and removal. For women who want the method immediately after giving birth, the lack of separate provider reimbursement also affects access.
“Many states have been working on increasing access to long-term contraception, specifically in the immediate postpartum period,” says Shanna Cox, MSHP, an associate director of science in the division of reproductive health at the Centers for Disease Control and Prevention in Atlanta.
Cox was a co-author of a study that looked at immediate postpartum insertions after delivery. The researchers compared it by state to see how much this practice varies by state and insurance status. The analysis includes 26 states and the District of Columbia in 2020.1
They found that the rate of LARC insertion immediately postpartum varied dramatically from state to state. On the lowest end, the rate was 2.6 LARC insertions per 10,000 deliveries. On the highest end, there were 637 LARC insertions per 10,000 deliveries.1
“There could be a lot of different reasons for that variation,” Cox says. “It was documenting how stark that variation was that is a key piece in the analysis in the paper.”
Investigators also found that immediate postpartum LARC insertions were higher for deliveries with Medicaid as the primary expected payor.1
The variation shows that state policies and provider knowledge of Medicaid and other payers’ requirements can help improve the rate of LARC insertions among women who desire this method to be inserted immediately postpartum.
“It’s really about how we can ensure — at the state level and with providers supporting women — that women have a choice and have access to convenient methods of contraception,” Cox explains. “An IUD can cost $600 to $1,000, and what many providers do is a global reimbursement payment for delivery, which is not enough to cover the additional cost of a LARC device and LARC insertion.”
Changing policies regarding how LARC is reimbursed and how clinicians counsel patients can help.
“Clinical guidance for contraceptive counseling for the postpartum period should be done during prenatal care,” Cox says. “Bringing this up during delivery is not the time. They need to provide contraceptive counseling during the prenatal period to prepare patients for the postpartum period.”
Any contraceptive counseling needs to be given without bias and coercion. Providers can discuss options and timing of certain options, such as LARC, but should not press their finger on the scale of a patient’s choice.
“There is some concern that providers may overemphasize LARC with certain communities, and we want to make sure women are given information for shared decision-making around which contraceptive they will use in the postpartum period,” Cox says. “They should not feel coerced into adopting certain methods.”
Providers who would like guidance on providing contraceptive information that is based solely on evidence and does not contain biases could use this guide from the Centers for Disease Control and Prevention (CDC): “Summary Chart of the U.S. Medical Eligibility Criteria for Contraceptive Use.”2
The color-coded, two-page chart lists various medical conditions, including postpartum as a condition. It shows which contraceptive methods could be used without restrictions, which have advantages that generally outweigh theoretical or proven risks, which have theoretical or proven risks that usually outweigh the advantages, and which have an unacceptable health risk and the method should not be used.2
The chart lists levonorgestrel IUD as safe without restrictions for non-breastfeeding women immediately postpartum. For those who are breastfeeding, the IUD has benefits that outweigh the risks.2
Providers need to ask patients prior to delivery what their breastfeeding goals are.
“It’s important for providers to be aware of the medical eligibility criteria of contraception for women in the postpartum period, for women who are breastfeeding,” Cox says.
Another strategy to improve contraceptive counseling and access to postpartum LARC is one that was successfully employed by the Delaware Contraceptive Access Now (CAN) program.3
Launched in 2014, Delaware CAN’s goal is to increase birth control access for all Delaware women, including those who desire immediate postpartum LARC.3
“Delaware has the highest rate of IUD insertion among all the states we looked at,” Cox says.
The Delaware CAN website provides people with a link to a chart of all of the various contraceptive methods and lists their effectiveness at preventing pregnancy if they are used correctly every time. It also has a link for people to find a Title X provider and information about the National Maternal Mental Health Hotline. Other information focuses on showing women how to create a reproductive life plan, including using contraception.3
Other differences in postpartum LARC insertions have to do with state policies involving Medicaid, including whether a state expanded the Medicaid program to include more low-income people.
“Differences in billing and coding practices may influence variation by state,” Cox says. “Some researchers have looked at comparing state policy to see how much that may explain the differences, and this is something the research field should continue to explore.”
Another new study found that changing Medicaid billing policy to allow for separate reimbursement of LARC devices from the global fee associated with a birth episode could increase the use of immediate postpartum LARC.4
Researchers also need to take a closer look at how maternal care deserts affect women’s ability to access the contraception of their choice in the postpartum period. For example, if a woman gives birth in the emergency department because the hospital lacks a maternity department, this could lead to her being offered little to no information about contraception and no access to a postpartum LARC insertion.
“It helps to think about the entire ecosystem of facilities throughout the state and how we can enhance the quality of services in all facilities so the facilities are prepared and have toolkits to meet the needs of the women they are serving,” she says. “Even emergency departments could have a toolkit.”
Health systems need to consider their own obstetric readiness and what they are able to offer patients.
“OB/GYN providers need to assess where a pregnant patient’s delivery will occur,” Cox says. “Each facility and each quality improvement collaborative should work at their individual state and jurisdiction level to see how they can work to improve care for clients.”
Individual providers and facilities can create their own systems and toolkits to meet the needs of their patients. For some facilities, this may include a focus on providing immediate postpartum LARC insertion if that is the patient’s choice.
“Perinatal quality initiatives can be more creative, and thinking about staffing needs could be a way to provide women with quality services in the facility’s own context,” Cox explains.
References
- Sharma K, Cox S, Romero L, et al. State variations in insertion of long-acting reversible contraception during delivery hospitalization. Contraception 2024;110509. [Online ahead of print].
- Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. Centers for Disease Control and Prevention. Updated in 2020. https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf
- Delaware CAN. Looking for birth control? DeThrives/Delaware Health and Human Services. https://dethrives.com/programs/delaware-can-contraceptive-access-now#what-is-delaware-can
- Rodriguez MI, Meath THA, Watson K, et al. Medicaid policy change and immediate postpartum long-acting reversible contraception. JAMA Health Forum 2024;5:r352359.
