A survey of OB/GYN residents revealed a significant difference in exposure to placement of intrauterine devices (IUDs) based on whether they were working as residents in states that expanded Medicaid vs. states that did not.1

More than 4,000 residents responded to the optional, anonymous survey, sent by the 2015-2016 Council on Resident Education in Obstetrics and Gynecology. The responses revealed those who worked in university programs in states that accepted Medicaid expansion inserted more IUDs and received more experience with immediate postpartum IUD training than did those in states that did not expand Medicaid.

“We asked five questions about IUD insertion,” says Megan L. Evans, MD, MPH, study co-author, assistant professor of OB/GYN at Tufts University School of Medicine and associate director of the OB/GYN residency program at Tufts Medical Center in Boston. “We compared where residents were and whether that state had expanded Medicaid, and we looked at comparable IUD insertion rates per resident. The study asked residents to estimate how many IUDs they had placed at the time of residency.”

Researchers wanted to know if Medicaid expansion affected the number of IUDs placed. They found the effect was only for residents trained in university settings. Those trained in community programs saw similar IUD insertion rates for both Medicaid expansion and non-expansion states.

“What’s unique is we had such a high response rate — 85% — which is hard [to achieve] in survey studies,” Evans says. “It was indicative of the resident population throughout the country.”

Since the survey was conducted in 2016, IUDs have increased in popularity as a contraceptive method. “IUDs have been on the rise for the last 15-plus years as a method of choice,” she says. “IUD insertions occur in a variety of locations and training sites, and it could be an outpatient clinic.”

The researchers asked about immediate postpartum IUD insertion in hospitals. “In states that expanded insurance, residents had higher rates of immediate postpartum placement than did residents who were not in expansion states,” Evans says.

The researchers did not look into the reasons why residents inserted more IUDs in Medicaid expansion states. “We didn’t get into that amount of information,” says Caitlin Dane, MD, MPH, OB/GYN resident physician at Tufts Medical Center. “The idea is when states accept Medicaid expansion, it expands the patient population that has access to these services, and expands the number that residents can interact with in the clinic or postpartum.”

When researchers broke down the data to compare community programs in expansion states vs. non-expansion states, they found no difference in IUD insertion rates among residents. The difference was significant only among residents at university sites.

“We looked at general training across both implants and IUDs, broken down by region of the country, and we saw it was the same in community programs,” Evans says. “It could be the patient population.”

Similar to their findings with general IUD use, they found that residents in expansion states had more training with immediate postpartum insertion of IUDs in university programs vs. those with immediate postpartum IUD training in non-expansion states.

“We were interested in the correlation between Medicaid expansion and training,” Dane says. “What we found was it’s possible that state and federal policy could impact training.”

States that expanded Medicaid and offered more access for patients would affect resident education because residents would receive more exposure to IUD placement, Dane adds.

The findings suggest residents’ IUD training in states without Medicaid expansion could be affected by that status.

“It could have potential impacts on patients down the line if they’re not getting the training in residency,” Evans says. “Because we care passionately about these issues, how policy impacts patient care, and how we practice medicine, [expanded Medicaid] has the potential to impact resident training.”


  1. Dane C, Breeze JL, Espey E, et al. Insurance expansion and intrauterine device training in obstetrics and gynecology. Am J Obstet Gynecol 2021 May 19;S0002-9378(21)00557-3. doi: 10.1016/j.ajog.2021.05.010. [Online ahead of print].