Pam Harrison

May 07, 2017

SAN DIEGO — Only a handful of women are receiving long-acting reversible contraception immediately after delivery, as recommended by the American College of Obstetricians and Gynecologists (ACOG), according to a study of postpartum trends in the United States.

The insertion of long-acting reversible conception immediately after delivery, such as implants and intrauterine devices (IUDs), is a relatively new service, and rates have increased in recent years, said investigator Lindsay Admon, MD, from the University of Michigan in Ann Arbor.

However, the rate "remains at less than 2% of the rate of tubal ligation," she said during a press briefing here at the American College of Obstetricians and Gynecologists 2017 Annual Meeting.

But even when sterilization is requested by women covered by Medicaid, almost half do not undergo the procedure immediately after delivery because a Medicaid consent form was completed incorrectly or unavailable, according to another study.

Maternity clinicians and policymakers should strive to ensure that women have full access to the contraceptive mix after childbirth.

"Maternity clinicians and policymakers should strive to ensure that women have full access to the contraceptive mix after childbirth, so they can make an informed, voluntary, and personal choice about whether and when to have another child," said Dr Admon.

Dr Admon and her colleagues identified patients in the National Inpatient Sample who had undergone tubal ligation, IUD insertion, or contraceptive implant insertion from 2008 to 2013.

Rates of postpartum sterilization did not change during the 5-year study period, but there was a sevenfold increase in the postpartum use of long-acting reversible conception (from 1.86 to 13.5 per 10,000 deliveries).

Women who received an IUD or implant were 92% more likely than those who received neither to have a medical comorbidity (adjusted odds ratio [OR], 1.92). And women covered by Medicaid or paying themselves were more than five times more likely than those with private insurance to receive an IUD or an implant (adjusted OR, 5.23).

The differences were much less pronounced for sterilization. Women with a medical comorbidity were slightly more likely than those without to undergo sterilization (adjusted OR, 1.17), as were women without private insurance (adjusted OR, 2.20).

Many Medicaid beneficiaries lose coverage 60 days after delivery, so they are likely highly motivated to initiate long-acting birth control, study investigator Michelle Moniz, MD, an obstetrician-gynecologist in Brighton, Michigan, told Medscape Medical News.

Women who gave birth at a teaching hospital were almost 15 times more likely than those who did not to receive an IUD or implant immediately after delivery (adjusted OR, 14.9). However, women who gave birth at an urban facility, as opposed to rural facility, were less likely to undergo sterilization (adjusted OR, 0.59).

The low uptake of postpartum long-acting reversible conception is likely the result of a previous reimbursement policy that did not allow physicians to claim for insertion immediately after delivery; they were reimbursed only when they the service was provided during the postpartum follow-up visit. Dr Admon told Medscape Medical News.

But this policy appears to be changing as physicians become more aware of the 60-day cutoff for Medicaid pregnancy coverage.

The Affordable Care Act enabled many women to obtain contraception and achieve their reproductive life plans, said Lynne Saito-Tom, MD, from the University of Hawaii in Honolulu. If barriers to birth control access are put in place in the United States, the number of unintended pregnancies is likely to increase, she added.

"We should continue to advocate for legislation to protect our patients' reproductive rights and access to affordable contraception," said Dr Saito-Tom. "We should also continue to educate our patients about the benefits of long-acting reversible contraceptives."

The mandated coverage of contraceptive care in the Affordable Care Act was a powerful change, said Dr Admon. "For the women I serve, the postpartum period is really a crucial time to access contraception — while they still have coverage in association with their pregnancies," she added.

Barriers to Sterilization

Barriers to postpartum sterilization were examined in a study of 334 women by Taylor Hahn, MD, from Indiana University in Indianapolis, and her colleagues.

"Our primary focus was to look at the effects of the consent form that is required for all of our patients who are covered by Medicaid for their prenatal care," she explained. The Medicaid consent form was implemented in 1976 to protect marginalized and vulnerable women from involuntary sterilization.

To determine rates of postpartum follow-up and interval sterilization, Dr Hahn's team looked at the records of women who requested postpartum sterilization.

Of the women who requested sterilization in the immediate postpartum period, 52% received it and 48% did not. For 37.9% of the women, the primary reason for an unfulfilled request was Medicaid consent.

When sterilization was not immediate, interval sterilization in the subsequent 3 months occurred in only 10% of women. In fact, almost one-quarter of women whose request went unfulfilled did not receive any postpartum care.

"So you have a lot of patients who really want postpartum sterilization, have expressed it multiple times throughout their prenatal care, but they can't get it because we don't have that form available for them," said Dr Hahn.

"For patients with private insurance, they don't need to sign any form. They can tell their physician the day of their delivery that they want postpartum sterilization and they can get it done," she explained. Although the "original intent of this Medicaid consent form was to make sure there was a waiting period, it has really created a barrier to women getting the care they want."

No One-Size-Fits-All Solution

Both these studies illustrate that there is not a one-size-fits-all solution for access to contraception, said Diane Horvath-Cosper, MD, a reproductive health advocacy fellow for Physicians for Reproductive Health in Baltimore.

"There may have been billing issues in terms of reimbursement for immediate postpartum long-acting reversible contraception, but there are also things like hospitals not stocking the contraceptive," she told Medscape Medical News. "For us, the process of getting the long-acting reversible contraceptive immediately postpartum is so onerous that sometimes we can't even get them to give to patients."

Giving birth can be a vulnerable time for women, she pointed out, and physicians should not be pushing one contraceptive method over another.

"Long-acting reversible contraceptives are very effective, but they are not the right choice for everybody," she added. But "postpartum sterilization — also very effective — isn't the right choice for everybody either."

"I want us to be in a place where we are giving people all of the options while understanding that for some people, postpartum is not the right time to get long-acting reversible contraception or sterilization," Dr Horvath-Cosper added.

Dr Admon, Dr Hahn, and Dr Horvath-Cosper have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting: Abstracts 33B and 14F. Presented May 6, 2017.

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