EXECUTIVE SUMMARY

After changing its Medicaid policy to provide reimbursement for immediate postpartum long-acting reversible contraception (LARCs) separate from the global labor and delivery payment, South Carolina saw an increase in immediate postpartum LARC initiation and increased birth spacing among young women.

  • While the rate of teen births has decreased in recent years, results of a 2017 analysis show that many teens continue to have repeat births. While most adolescent mothers are taking steps to prevent another pregnancy, one in three is using either a least-effective method or no contraception at all, data indicate.
  • Repeat teen births, defined as two or more live births before age 20, can have multiple effects on both mother and baby. Repeat births can impede an adolescent mother’s ability to take advantage of educational and workforce opportunities.

By changing its Medicaid policy change to provide reimbursement for immediate postpartum long-acting reversible contraception (LARC) separate from the global labor and delivery payment, South Carolina saw an increase in immediate postpartum LARC initiation and increased birth spacing among young women.1

While the rate of teen births has decreased in recent years, results of a 2017 analysis shows that that many teens still have repeat births. While most adolescent mothers are taking steps to prevent another pregnancy, one in three is using either a least-effective method or no contraception at all, data indicate.2

Repeat teen births, defined as two or more live births before age 20, can have multiple effects on both mother and baby. Repeat births can impede an teen mother’s access to work and educational opportunities.3 Babies who are born of repeat teen pregnancies are more likely to be preterm or of low birth weight than first teen births.4

Insertion of LARC methods, such as an intrauterine device (IUD) or implant, in the immediate postpartum period has traditionally been wrapped into the Medicaid maternity care payment. If the state does not have a specific Medicaid policy for immediate postpartum placement, providers are not specifically reimbursed for such insertions. South Carolina’s Medicaid program changed its reimbursement practices in 2012 to include separate payments.

Maria Steenland, a postdoctoral fellow in population studies at Brown University, and colleagues examined some 243,000 Medicaid childbirth hospitalizations from 2010 to 2017. Their analysis suggests that following the reimbursement change, more women received LARCs immediately after childbirth, increasing from 0.07% for adults and teenagers in 2010 to 5.65% for adults and 10.48% for teenagers by December 2017.

The rate of adolescent short-interval births (defined as subsequent childbirth within 21 months), which had been on the rise before the reimbursement change, flattened and was about 5.3% lower than the projected rate. In contrast, there were no significant changes in short-interval birth rates among adults, researchers report.1

Pushing for Change

Medicaid covers more than 70% of family planning services for low-income Americans and pays for nearly half of all U.S. births.5 By increasing access to contraceptives for Medicaid enrollees, states can improve health outcomes and reduce costs.

Currently, 37 states have changed their Medicaid policies to reimburse immediate postpartum LARC separately from the global fee for delivery. While some states have implemented changes to include Medicaid reimbursement policies for immediate postpartum LARC, not all hospitals have adopted such services due to challenges of managing supply chain and revenue cycle issues, training providers how to offer LARC in a patient-centered way, and revising billing and claims processing mechanisms.

The American College of Obstetricians and Gynecologists (ACOG) LARC Program created the Postpartum Contraceptive Access Initiative to provide training for immediate postpartum LARC implementation. (Information is available at: https://bit.ly/2YpLDLJ.)

Immediate postpartum LARC insertion is recognized by ACOG as a best practice for its prevention of rapid repeat and unintended pregnancy.6-8 Immediate postpartum is particularly favorable for IUD or implant insertion.

Placing an IUD within 10 minutes after delivery or inserting a contraceptive implant prior to discharge home after a birth has many benefits for the woman. Recent research indicates that postpartum insertion of a hormonal IUD does not affect a woman’s ability to lactate and breastfeed.

REFERENCES

  1. Steenland MW, Pace LE, Sinaiko AD, et al. Association between South Carolina Medicaid’s change in payment for immediate postpartum long-acting reversible contraception and birth intervals. JAMA 2019; doi:10.1001/jama.2019.6854.
  2. Dee DL, Pazol K, Cox S, et al. Trends in repeat births and use of postpartum contraception among teens — United States, 2004-2015. MMWR Morb Mortal Wkly Rep 2017; 66:422-426.
  3. Klerman L. Another Chance: Preventing additional births to teen mothers. Washington, DC: National Campaign to Prevent Teen and Unplanned Pregnancy; 2004. Available at: https://bit.ly/32fnZR3.
  4. Gavin L, Warner L, O’Neil M, et al. Vital signs: Repeat births among teens—United States, 2007-2010. MMWR Morb Mortal Wkly Rep 2013; 62:249-55.
  5. Association of State and Territorial Health Officials. Increasing access to contraception learning community year three. Project Summary. Arlington, VA; 2018.
  6. Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice bulletin 186: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2017;130:e251-e269.
  7. American College of Obstetricians and Gynecologists. Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Committee Opinion No. 642. Obstet Gynecol 2015;126:e44-48.
  8. American College of Obstetricians and Gynecologists. Immediate postpartum long-acting reversible contraception. Committee Opinion No. 670. Obstet Gynecol 2016;128:e32-37.
  9. Turok DK, Leeman L, Sanders JN, et al. Immediate postpartum levonorgestrel intrauterine device insertion and breastfeeding outcomes: A noninferiority randomized controlled trial. Am J Obstet Gynecol 2017;doi:10.1016/j.ajog.2017.08.003.