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Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

Background: There is little research examining adherence to practice guidelines for long-acting reversible contraception (LARC). We assessed same-day LARC provision and adherence to other guideline-recommended practices among providers in a large academic health care system. Materials and Methods: We surveyed 363 providers who had billed using LARC-related codes within the prior 12 months. Primary outcomes were, for women requesting an intrauterine device (IUD) or implant, the typical number of visits for method provision and ability to add an insertion procedure to an annual examination. We used chi-square tests and multivariable logistic regression to identify characteristics associated with primary outcomes and described other practices and barriers to same-day LARC. Results: Our response rate was 42% (153/363). A typical single visit for women requesting an IUD or implant was reported by 37% of IUD providers and 51% of implant providers, respectively, and was associated with obstetrician-gynecologist specialty versus family medicine (IUD: 44% vs. 12%, p  = 0.001; implant: 57% vs. 26%, p  = 0.002) and practicing in the county of the main academic medical center versus any other county (IUD: 48% vs. 20%, p  = 0.001; implant: 65% vs. 27%, p  < 0.001). High ability to add LARC insertion to an annual examination was reported by 48% of IUD providers and 51% of implant providers, with similar associations of specialty and county. Barriers to same-day LARC included scheduling constraints, insurance and billing concerns, and device stocking. Nearly all respondents provide LARC to nulliparous women and adolescents. Among IUD providers, 73% schedule routine follow-up after insertion. Conclusions: Same-day LARC provision is low among providers in a large academic health care system. Provider-identified barriers suggest interventions to improve LARC access, including incentivizing device stocking and billing and insurance education.

Background: Rapid repeat pregnancy (RRP) is common among adolescents and is associated with adverse maternal and infant outcomes. Despite evidence that use of long-acting forms of contraception before hospital discharge can help minimize RRP rates, barriers to placement existed within the state of Indiana. We sought to determine state-specific RRP and induced abortion rates for adolescents based on chosen postpartum contraception to inform policy change. Methods: We examined a retrospective cohort of 227 adolescents (ages 12-18 years) who gave birth in Indiana between 2010 and 2012. Demographics, postpartum contraception, and subsequent pregnancies or abortions after the sentinel delivery were obtained. Rates of RRP based on type of immediate postpartum contraception, etonogestrel (ENG) contraceptive implant, depo-medroxyprogesterone acetate (DMPA) injection, and short-acting methods were compared. Bivariate and logistic regression analyses were conducted. Results: RRP rates were 3.7% for those with ENG contraceptive implant, 22.6% for those with DMPA, and 39.1% for those who choose short-acting methods ( p  = 0.01). Adolescents who did not choose an ENG contraceptive implant were significantly more likely to have an RRP (adjusted odds ratio [aOR] = 11.8, 95% confidence interval: 2.74-110.3), compared with other contraceptive methods, even after adjusting for covariates such as age, prior pregnancies, and postpartum visit attendance. Conclusions: Immediate postpartum receipt of ENG implant was significantly associated with a lower likelihood of RRP in adolescents in Indiana. These data facilitated state policy change regarding insurance reimbursement to improve statewide access for all women, regardless of age, showing how local data can inform policy change.

Background: To investigate the hypothesis that increased uptake of long-acting reversible contraception (LARC) by women played a role in the declining abortion rates observed in New Zealand between 2008 and 2014. Materials and Methods: This quantitative ecological study analyzed routinely collected national data pertaining to abortion numbers, contraceptive prescriptions, and census population estimates for the period 2004-2014. Annual prescription and prevalence rates (per 1000 women) were calculated for short- and long-acting methods to investigate changes over time. Poisson's regression was used to (1) test whether the abortion rate changed by year; (2) whether 2010 (when the contraceptive implant became subsidized) was a significant point of change; and (3) test the relationship between declining abortions and patterns of contraceptive use. Results: Estimated LARC prevalence increased from 2009 to 2014, with a corresponding decrease observed in prescription of short-acting methods. The declining abortion rate accelerated each year from 2008 to 2014 (with a faster decline from 2010 to 2014), but 2010 was not a significant point of change. Three factors had statistically significant associations with declining abortion rates ( p  < 0.01): year (acting as a surrogate for all social changes), women's use of the levonorgestrel (LNG)-implant, and the combined model: use of the LNG-implant and copper intrauterine device (CuIUD) had the best fit (using Akaike's Information Criterion), indicating that this variable explained more of the year-to-year variability in abortion rates. Conclusions: The shift toward women's increased use of the two publically funded LARC methods (LNG-implants and CuIUD) was significantly associated with the declining abortion rates in New Zealand.

Objective: We sought to evaluate whether differences in rates of contraceptive discontinuation exist among black and white women receiving contraceptive counseling and no-cost contraception among users of long-acting reversible contraceptive (LARC; intrauterine devices or subdermal implant) and non-LARC (oral contraceptive pills, contraceptive vaginal ring, patch, or injection) methods., Materials and Methods: We analyzed data from a prospective cohort study of 7546 non-Hispanic black and white women who participated in the Contraceptive CHOICE Project. Among women who initiated their method within 12 weeks of enrollment, discontinuation was defined as any break in use longer than 1 month. Using Cox proportional hazards regression analysis, we estimated discontinuation stratified by use of LARC methods., Results: There were no statistically significant differences in contraceptive discontinuation between black and white women at 12, 24, or 36 months among both LARC [12-month adjusted hazard ratio (HR adj-12M ) 1.01 (95% confidence interval or 95% CI 0.86-1.18); HR adj-24M 1.10 (95% CI 0.97-1.24); and HR adj-36M 1.10 (95% CI 0.98-1.23)] and non-LARC users [HR adj-12M 1.08 (95% CI 0.92, 1.26); HR adj-24M 1.07 (95% CI 0.94, 1.23); and HR adj-36M 1.08 (95% CI 0.95, 1.23)] adjusting for confounders. Secondary analyses found no significant differences in discontinuation of LARC and non-LARC methods among black and white women at highest risk of pregnancy or those receiving public assistance at baseline., Conclusions: At 12, 24, and 36 months there were no differences in contraceptive discontinuation of both LARC methods and non-LARC methods when comparing white and black women.

Objective: Nulliparous women in the United States have high rates of unintended pregnancy comparable with parous women. Long-acting reversible contraceptives (LARCs) are recommended as first-line contraceptive choices to reduce unintended pregnancy. However, use of LARCs among nulliparous women has been low. This study aims to examine changes in the prevalence of current LARC use among sexually experienced U.S. nulliparous women across the time period of 2006-2010, 2011-2013, and 2013-2015, and examine correlates of use., Materials and Methods: Sexually experienced nulliparous women (15-44 years) from the 2006-2010, 2011-2013, and 2013-2015 rounds of the National Survey of Family Growth (N = 7463) were examined. Changes in the prevalence of current use of LARCs were examined and correlates of current LARC use were evaluated using multiple logistic regression., Results: Increases in the prevalence of current LARC use from 2008 to 2012 (0.8% vs. 3.8%, p < 0.0001) and from 2012 to 2014 (3.8% vs. 5.7%, p = 0.09) were observed among sexually experienced nulliparous women. Significant increases were also observed across different subgroups of nulliparous women. Maternal age, education, future birth intention, sexual activity, and discontinuation of non-LARC hormonal contraceptives due to dissatisfaction were significant correlates of current LARC use., Conclusion: Although current use of LARCs among sexually experienced U.S. nulliparous women shows an increasing trend, prevalence of use still remains low. There is the need to increase awareness of LARCs as an effective contraceptive choice for nulliparous women.

Objective: To assess temporal trends in the uptake and continuation of the etonogestrel subdermal implant in a large private practice setting., Methods: This was a retrospective cohort study based on billing records from a large multispecialty private practice in Las Vegas, Nevada. We looked at women of all ages seeking long-acting reversible contraception (LARC) between January 1, 2013, and December 31, 2016. The main outcome measure was uptake of the etonogestrel subdermal implant, expressed as a fraction of all insertions of LARC across four calendar years (2013-2016). The Kaplan-Meier method was used to estimate 12-month continuation stratified by year of insertion., Results: There were 3477 total LARC insertions across the 4-year study period. In unadjusted analyses, the uptake of the etonogestrel implant increased from 3.0% of LARC insertions in 2013 to 9% in 2016 among women aged 30 years and older. For women younger than 30 years, the uptake of the implant stayed stable from 2013 to 2015 (22.8%, 21.7%, and 22.4%, respectively), but increased to 30.9% in 2016. We modeled the uptake of the implant as a function of year of insertion adjusted for age (continuous) and insurance status (private vs. Medicaid), and we stratified the models by age (younger than 30 years, 30 years, and older than 30 years). The positive association between year of insertion and uptake of the implant was significantly stronger for women aged 30 years and older, compared to women younger than 30 years. There was a progressive decrease in the 12-month continuation of implant from 2013 (95.7%) to 2015 (57.7%)., Conclusions: In this large private practice setting, among women aged 30 years and older, we observed a threefold increase in the uptake of the subdermal implant from 2013 to 2016. We also observed a significant decrease in the 12-month continuation of the implant over time. Further studies of implant uptake and continuation in the private practice setting are needed.