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Trends in use of long-acting reversible contraception during delivery hospitalizations, 2000–2019

      Objective

      Intrauterine device (IUD) or contraceptive implant placement after delivery can help reduce unintended and short-interval pregnancies and improve outcomes. The American College of Obstetricians and Gynecologists supports providing long-acting reversible contraception (LARC) immediately after childbirth, and the National Quality Forum endorsed the practice as a high-quality care measure.
      American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice
      Committee Opinion No. 670: immediate postpartum long-acting reversible contraception.
      ,
      National Quality Forum perinatal and reproductive health 2015–2016 final report.
      Currently, 38 states have Medicaid reimbursement policies for LARC placement after delivery.
      • Kroelinger C.D.
      • Okoroh E.M.
      • Uesugi K.
      • et al.
      Immediate postpartum long-acting reversible contraception: review of insertion and device reimbursement policies.
      • Brown J.A.
      • Greenfield L.T.
      • Rapkin R.B.
      Special report: implementing immediate postpartum LARC in Florida.
      • Lacy M.M.
      • McMurtry Baird S.
      • Scott T.A.
      • Barker B.
      • Zite N.B.
      Statewide quality improvement initiative to implement immediate postpartum long-acting reversible contraception.
      To determine how practice patterns changed in the setting of these payment reforms and clinical recommendations, we analyzed trends in a large administrative database.

      Study Design

      We conducted a serial cross-sectional analysis of delivery hospitalizations of patients aged 15 to 54 years included in the National Inpatient Sample (NIS) from 2000 to 2019. The NIS is a publicly available, all-payer inpatient database that approximates a 20% stratified sample of US hospitals. We identified delivery hospitalizations using validated criteria, excluding deliveries associated with hysterectomy. We characterized temporal trends in use of IUD, implants, or both during delivery hospitalizations using Joinpoint Regression Program, version 4.8.0.1 (National Cancer Institute, Bethesda, MD) to calculate the average annual percent change (AAPC) with 95% confidence intervals (CIs). We performed unadjusted and adjusted logistic regression to evaluate the association between demographic and clinical factors and likelihood of receiving inpatient LARC, reporting unadjusted and adjusted odds ratios (aORs) with 95% CIs as measures of association. In an ancillary analysis, we applied NIS population weights to evaluate national temporal trends. This analysis was deemed exempt by the Columbia University Institutional Review Board.

      Results

      After applying study criteria, 15,917,829 deliveries were included in the analysis. The rate of LARC insertion during delivery hospitalization increased from 0.7 to 123.6 per 10,000 nonhysterectomy deliveries from 2000 to 2019 (Figure, A), whereas rates of tubal sterilization fell from 741.1 to 634.2 per 10,000 nonhysterectomy deliveries over the same interval (data not shown). The trend for inpatient LARC in the general obstetrical population demonstrated an inflection in 2013 in a 3-joinpoint model, with an AAPC of 42.5% (95% CI, 36.5%–48.7%) from 2013 to 2019. By 2019, LARC was placed in 226.5 per 10,000 nonhysterectomy deliveries among Medicaid beneficiaries (AAPC, 2013–2019, 43.3%; 95% CI, 36.9%–49.9%) vs 43.5 per 10,000 among the commercially insured (AAPC, 2013–2019, 44.9%; 95% CI, 38.4%–51.6%) (Figure, B). Deliveries to women with non-Hispanic Black (aOR, 2.06; 95% CI, 2.00–2.13) and Hispanic (aOR, 1.84; 95% CI, 1.78–1.90) race and ethnicity, Medicaid insurance (aOR, 3.59; 95% CI, 3.48–3.71), lowest ZIP code-income quartile (aOR, 1.64; 95% CI, 1.58–1.71), and deliveries at urban teaching hospitals (aOR, 6.11; 95% CI, 5.81–6.43) had higher odds of inpatient LARC (Supplemental Table). After applying population weights, an estimated 76,635,914 deliveries demonstrated similar trends and adjusted models (data not shown).
      Figure thumbnail gr1
      FigureProportion of delivery hospitalizations with LARC by year
      A, demonstrates the proportion of delivery hospitalizations associated with contraceptive implant, IUD, or any LARC among deliveries without hysterectomy in the NIS from 2000 to 2019. B, demonstrates the proportion of delivery hospitalizations associated with any LARC among deliveries without hysterectomy in the NIS from 2000 to 2019, stratified by payer. For simplicity, only deliveries associated with Medicaid and commercial insurance are shown. These payers were associated with 93.4% of nonhysterectomy deliveries in the NIS from 2000 to 2019. For any LARC, the AAPC per 10,000 deliveries without hysterectomy with 95% CI was 28.7% (−5.3% to 75.0%) from 2000 to 2013 and 42.5% (36.5%–48.7%) from 2013 to 2019. For contraceptive implant, the AAPC per 10,000 deliveries without hysterectomy with 95% CI was 22.8% (−22.7% to 95.2%) from the 2000 to 2013 and 44.6% (38.2%–51.3%) from 2013 to 2019. For intrauterine devices, the AAPC per 10,000 deliveries without hysterectomy with 95% CI was 36.2% (7.0%–73.5%) from 2000 to 2013 and 37.6% (30.9%–44.6%) from 2013 to 2019. B, demonstrates the proportion of delivery hospitalizations associated with any LARC among deliveries without hysterectomy in the NIS from 2000 to 2019, stratified by payer. For simplicity, only deliveries associated with Medicaid and commercial insurance are shown. These payers were associated with 93.4% of nonhysterectomy deliveries in the NIS from 2000 to 2019. For Medicaid, the AAPC per 10,000 deliveries without hysterectomy for any LARC with 95% CI was 27.7% (−11.7% to 84.9%) from 2000 to 2013 and 43.3% (36.9%–49.9%) from 2013 to 2019. For commercial insurance, the AAPC per 10,000 deliveries without hysterectomy for any LARC with 95% CI was 22.6% (10.5%–36.0%) from 2000 to 2013 and 44.9% (38.4%–51.6%) from 2013 to 2019.
      AAPC, average annual percent change; CI, confidence interval; IUD, intrauterine device; LARC, long-acting reversible contraception; NIS, National Inpatient Sample.
      van Biema. Trends in use of long-acting reversible contraception during delivery hospitalizations. Am J Obstet Gynecol 2022.

      Conclusion

      Use of immediate postpartum LARC among Medicaid beneficiaries dramatically increased after 2013, suggesting increased uptake in the setting of Medicaid payment reforms and clinical recommendations. Inpatient LARC use also increased among a smaller proportion of the commercially insured from 2013 to 2019.
      • Kroelinger C.D.
      • Okoroh E.M.
      • Uesugi K.
      • et al.
      Immediate postpartum long-acting reversible contraception: review of insertion and device reimbursement policies.
      Low-income women and non-Hispanic Black and Hispanic women were significantly more likely to receive inpatient LARC from 2000 to 2019. These populations have higher rates of Medicaid enrollment. Further research is indicated to ensure that LARC use is optimal in fulfilling the contraceptive needs and preferences for these populations.

      Appendix

      Supplemental TableUnadjusted and adjusted odds for immediate postpartum long-acting reversible contraception among deliveries without a hysterectomy (unweighted)
      Demographic, hospital and clinical factorsUnadjusted odds ratio (95% CI)for LARC at deliveryAdjusted odds ratio (95% CI)for LARC at delivery
      Risk factors
      Hospital region
       NortheastRefRef
       Midwest0.65 (0.63–0.67)0.73 (0.71–0.76)
       South0.58 (0.57–0.60)0.56 (0.54–0.57)
       West0.72 (0.70–0.74)0.78 (0.75–0.81)
      Hospital location and teaching status
       Urban, nonteachingRefRef
       Urban, teaching13.59 (12.93–14.28)6.11 (5.81–6.43)
       Rural1.18 (1.07–1.30)0.75 (0.68–0.83)
      Hospital bed size
       SmallRefRef
       Medium1.05 (1.01–1.10)1.38 (1.32–1.44)
       Large1.84 (1.77–1.91)2.97 (2.86–3.09)
      Age category
       15–19 y old1.37 (1.32–1.42)1.74 (1.67–1.80)
       20–24 y old1.19 (1.15–1.22)1.20 (1.17–1.24)
       25–29 y oldRefRef
       30–34 y old0.80 (0.78–0.83)0.89 (0.86–0.91)
       35–39 y old0.78 (0.75–0.81)0.79 (0.76–0.83)
       40–54 y old0.76 (0.70–0.82)0.67 (0.62–0.73)
      Maternal race
       Non-Hispanic WhiteRefRef
       Non-Hispanic Black4.79 (4.65–4.94)2.06 (2.00–2.13)
       Hispanic3.26 (3.17–3.36)1.84 (1.78–1.90)
       Other2.34 (2.25–2.44)1.71 (1.64–1.78)
       Unknown0.46 (0.43–0.49)1.48 (1.40–1.57)
      Payer
       Medicare8.66 (7.92–9.46)5.30 (4.83–5.80)
       Medicaid5.69 (5.53–5.86)3.59 (3.48–3.71)
       Private insuranceRefRef
       Self-pay2.84 (2.65–3.04)2.72 (2.54–2.92)
       No charge1.98 (1.44–2.71)2.98 (2.17–4.10)
       Other1.83 (1.67–2.00)1.78 (1.63–1.95)
      ZIP code-income quartile
       First quartile4.83 (4.66–5.02)1.64 (1.58–1.71)
       Second quartile2.32 (2.23–2.42)1.25 (1.20–1.31)
       Third quartile1.91 (1.83–1.99)1.20 (1.15–1.25)
       Fourth quartileRefRef
      Year of delivery
       2000RefRef
       20010.72 (0.48–1.09)0.76 (0.50–1.14)
       20020.56 (0.37–0.87)0.58 (0.38–0.89)
       20030.40 (0.25–0.65)0.35 (0.22–0.57)
       20040.52 (0.34–0.81)0.46 (0.30–0.72)
       20050.51 (0.33–0.80)0.43 (0.28–0.67)
       20060.42 (0.26–0.67)0.33 (0.20–0.52)
       20070.83 (0.57–1.21)0.64 (0.44–0.94)
       20082.65 (1.96–3.60)2.06 (1.52–2.79)
       20092.55 (1.87–3.47)1.65 (1.21–2.25)
       201015.28 (11.65–20.03)9.91 (7.54–13.01)
       20117.56 (5.72–9.99)4.80 (3.64–6.34)
       201217.63 (13.46–23.10)13.04 (9.95–17.09)
       201320.24 (15.47–26.49)14.87 (11.35–19.47)
       201431.48 (24.12–41.09)20.73 (15.87–27.08)
       201547.45 (36.41–61.84)31.51 (24.16–41.10)
       201670.33 (54.02–91.57)46.52 (35.70–60.62)
       2017110.50 (84.93–143.77)70.40 (54.05–91.68)
       2018146.46 (112.61–190.50)92.66 (71.16–120.64)
       2019180.50 (138.80–234.73)113.97 (87.55–148.36)
      Obstetrical factors
       Multiple gestation1.28 (1.19–1.37)1.19 (1.11–1.28)
      Medical comorbidities
       Pregestational diabetes mellitus3.42 (3.21–3.64)1.71 (1.60–1.83)
       Obesity5.19 (5.04–5.33)1.74 (1.69–1.79)
       Chronic hypertension2.80 (2.65–2.96)1.44 (1.36–1.53)
      The adjusted model included maternal age category, race, payer, income quartile, hospital location and teaching status, hospital region, hospital bed size, year of delivery, obstetrical factors (multiple gestation) and medical comorbidities (pregestational diabetes mellitus, obesity, and chronic hypertension).
      CI, confidence interval; LARC, long-acting reversible contraception; Ref, reference interval.
      van Biema. Trends in use of long-acting reversible contraception during delivery hospitalizations. Am J Obstet Gynecol 2022.

      References

        • American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice
        Committee Opinion No. 670: immediate postpartum long-acting reversible contraception.
        Obstet Gynecol. 2016; 128: e32-e37
      1. National Quality Forum perinatal and reproductive health 2015–2016 final report.
        (Available at:)
        • Kroelinger C.D.
        • Okoroh E.M.
        • Uesugi K.
        • et al.
        Immediate postpartum long-acting reversible contraception: review of insertion and device reimbursement policies.
        Womens Health Issues. 2021; 31: 523-531
        • Brown J.A.
        • Greenfield L.T.
        • Rapkin R.B.
        Special report: implementing immediate postpartum LARC in Florida.
        Am J Obstet Gynecol. 2020; 222: S906-S909
        • Lacy M.M.
        • McMurtry Baird S.
        • Scott T.A.
        • Barker B.
        • Zite N.B.
        Statewide quality improvement initiative to implement immediate postpartum long-acting reversible contraception.
        Am J Obstet Gynecol. 2020; 222: S910.e1-S910.e8