Implement Resources for Immediate Postpartum LARC to Cut Unintended Pregnancy
EXECUTIVE SUMMARY
Although efforts to expand access to the full range of contraceptive methods available immediately postpartum are increasing, state- and hospital-level barriers to provision remain.
To understand the most important steps required to implement immediate postpartum long-acting reversible contraception (LARC) programs in different Georgia hospitals and the barriers to implementing such a program, researchers interviewed 32 key personnel from 10 state hospitals working to establish immediate postpartum LARC programs. At the completion of the study, LARC was available for immediate postpartum placement at seven of the 10 hospitals.
The American College of Obstetricians and Gynecologists recently issued a new Committee Opinion on the use of LARC. Its LARC Program also has gathered a variety of additional resources to support immediate postpartum LARC implementation.
Efforts to expand access to the full range of contraceptive methods available immediately postpartum are increasing; however, state- and hospital-level barriers to provision remain.
Unplanned pregnancies can happen in the postpartum period — data indicate between 40-57% of women report engaging in unprotected intercourse before the routine six-week postpartum visit.2,3 (Contraceptive Technology Update reported on the move to increase postpartum LARC placement; see the October 2016 article, “Counsel On Convenience & Effectiveness of Immediate Postpartum LARC,” available at: http://bit.ly/2nqXI16.) Clinicians may plan to provide women with contraception at their postpartum follow-up visit. However, up to 40% of women do not attend a follow-up appointment, and, thus, never obtain a prescription for birth control.4
To understand the most important steps required to implement immediate postpartum long-acting reversible contraception (LARC) programs in different Georgia hospitals and the barriers to implementing such a program, researchers in the Atlanta-based Emory University School of Medicine Department of Gynecology and Obstetrics interviewed 32 key personnel from 10 Georgia hospitals working to establish immediate postpartum LARC programs. The researchers used the Chapel Hill, NC-based National Implementation Research Network’s Stages of Implementation to organize participant-identified key steps for immediate postpartum LARC into an implementation guide. The scientists then compared this guide to hospitals’ implementation experiences. At the completion of the study, LARC was available for immediate postpartum placement at seven of the 10 study hospitals.1
“Georgia was one of the early states to adopt Medicaid coverage for immediate postpartum IUD and implant placement; however, there is very little evidence about how to put this into practice,” explains Melissa Kottke, MD, MPH, MBA, director of the Jane Fonda Center and associate professor in the department of gynecology and obstetrics at Emory University School of Medicine. “With this study, we sought to understand the implementation of immediate postpartum LARC, and describe its complexities, barriers, and facilitators, in hospitals in Georgia.”
Identify the Steps
In April 2014, Georgia Medicaid approved separate reimbursement for immediate postpartum LARC. The Georgia Perinatal Quality Collaborative, a multidisciplinary group formed to identify and implement quality improvement strategies to improve maternal and neonatal care and outcomes in the state, chose immediate postpartum LARC as a key initiative. Participating hospitals agreed to implement immediate postpartum LARC programs.
Physicians, nurses, pharmacists, billing personnel, and lactation consultants were interviewed for the study. Most study participants held both clinical and administrative positions within their hospitals; the majority had no experience with currently available LARC methods.1
Hospitals participating in the project identified common themes for the implementation experience: team member identification and ongoing communication, payer preparedness challenges, interdependent department-specific tasks, and piloting with continuing improvements. Anticipatory guidance was needed throughout the process, participants agreed.
Key first steps identified to implement immediate postpartum LARC included:
- identifying project champions;
- creating an implementation team that included all relevant departments;
- obtaining financial reassurance;
- ensuring hospital administration awareness of the project.
What were some of the potential barriers? Researchers identified lack of knowledge about immediate postpartum LARC, financial concerns, and competing clinical and administrative priorities as some of the hurdles encountered in program implementation. Hospitals that were successful at implementing immediate postpartum LARC programs did so by prioritizing clear communication and multidisciplinary teamwork, researchers found.
Guide Outlines Steps
An important outcome from the study is its guide, which organizes the key steps for program implementation, based on aggregate experiences from different Georgia hospitals. (Access it at: http://bit.ly/2nr1VSk.) A stage-based approach to implementation and a standardized guide detailing these steps may provide the necessary structure for the complex process of implementing immediate postpartum LARC programs in the hospital setting, according to researchers.1
Although the guide reflects a comprehensive assessment of the steps to implementing immediate postpartum LARC programs, not every step of the guide is necessary for successful implementation. Researchers identified three essential elements for starting the process. First, early involvement of the necessary members of the implementation team will lead to better communication and understanding of the project. Teams should include direct clinical care, pharmacy, or finance and billing perspectives. The specific team members may vary depending on the hospital and may include additional roles, researchers state.1
“Implementation cannot move forward without financial reassurance early in the process,” researchers note. “Finally, consistent communication and team planning with clear roles and responsibilities are key to navigating the complex and interconnected steps for implementing immediate postpartum LARC programs.”
Get on Board
Some state coalitions and agencies also have gathered information on navigating other immediate postpartum LARC barriers. The South Carolina Postpartum LARC Toolkit (available at: http://bit.ly/2d1X4Qj) and the Texas LARC Toolkit (available at: http://bit.ly/2mSj71D) include such items as materials addressing clinical resources and training, hospital billing and reimbursement, contraceptive counseling, and implementation planning.
The American College of Obstetricians and Gynecologists (ACOG) recently issued a new Committee Opinion on the use of LARC.5 The ACOG LARC Program also has gathered a variety of additional resources to support immediate postpartum LARC implementation, including the payment and policy approaches of 26 state Medicaid programs for reimbursement of immediate postpartum LARC. (See all the resources at: http://bit.ly/2n2P3Rw.) According to information from the Arlington, VA-based Association of State and Territorial Health Officials, both Oregon and Vermont are considering bills to allow the state Medicaid agency to reimburse for immediate postpartum LARC insertions. This intervention has the potential to reduce unintended and short-interval pregnancies.
In September 2016, the Kaiser Family Foundation published the results of its Medicaid Coverage of Family Planning Benefits Survey, which found that states are considering and implementing various reimbursement structures for postpartum LARC insertion. (Access the report at: http://kaiserf.am/2mMFmV7.) The report outlines how 41 states currently reimburse for postpartum LARC placement.
Advocacy grows for immediate postpartum LARC. The CDC has established the 6/18 Initiative, a partnership between purchasers, payers, and providers, which sees insurance coverage of immediate postpartum LARC to positively affect both health and costs. The initiative is working to ensure that both public and private payers reimburse for immediate postpartum LARC insertion by unbundling payment for LARC from other postpartum services.
Immediate postpartum LARC is an important strategy to help interested women obtain LARC methods after childbirth, per a recently published editorial on the subject.6
“Combined efforts from clinicians, clinical leadership, payers, and researchers can accelerate the adoption and availability of immediate postpartum contraception,” the editorial states. “For women to be fully empowered to improve their and their children’s health, they need access to immediate postpartum contraception.”
In a time of uncertainty about future availability of LARC methods, timely development of postpartum IUD and implant policies becomes particularly important, says Anita Nelson, MD, professor and chair of the obstetrics and gynecology department at Western University of Health Sciences in Pomona, CA.
REFERENCES
- Hofler LG, Cordes S, Cwiak CA, et al. Implementing immediate postpartum long-acting reversible contraception programs. Obstet Gynecol 2017;129:3-9.
- Brito MB, Ferriani RA, Quintana SM, et al. Safety of the etonogestrel-releasing implant during the immediate postpartum period: A pilot study. Contraception 2009;80:519-526.
- Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: A longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:263-267.
- Gurtcheff SE, Turok DK, Stoddard G, et al. Lactogenesis after early postpartum use of the contraceptive implant: A randomized controlled trial. Obstet Gynecol 2011;117:1114-1121.
- Committee Opinion No. 670: Immediate postpartum long-acting reversible contraception. Obstet Gynecol 2016;128:e32-37.
- Moniz M, Chang T, Heisler M, et al. Immediate postpartum long-acting reversible contraception: The time is now. Contraception 2016; doi/10.1016/j.contraception.2016.11.007.
Many women engage in unprotected sex before six-week postpartum visit.
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