Increased access to immediate postpartum LARC improves birth outcomes

Maria Steenland, SD, a research assistant professor at the Population Studies and Training Center, Brown University, Providence, Rhode Island.

“The relationship between postpartum contraception, birth intervals and infant outcomes is often assumed, and underscores a lot of family planning research and policy,” said principal investigator Maria Steenland, SD, a research assistant professor at the Population Studies and Training Center, Brown University, Providence, Rhode Island. “However, very little research has investigated the relationship between postpartum family planning and infant outcomes.”

The study focused on South Carolina’s Medicaid program, which in 2012, began to reimburse hospitals for immediate postpartum LARC and separate from the global maternity payment.

A sample of 186,953 Medicaid-paid births in the state between January 2009 and December 2015 were assessed—81,110 births from 2009 to 2011 (prior to policy change); 105,843 births from 2012 to 2015 (post-policy change); and 46,414 births in exposure hospitals (birth in an implementing-policy hospital between 2012 and 2015).

The policy was linked to an absolute 5.6% increase in the overall probability of receiving an immediate postpartum LARC.

Most pronounced was the effect on non-Hispanic Black women, among whom the increase in immediate postpartum LARC was 3.54 percentage points greater than for non-Hispanic White women (P = 0.002).

The policy was also associated with a 0.4% decrease in the probability of subsequent preterm birth and a 0.3% reduction in the likelihood of subsequent low birth weight.

However, there were no significant differences in policy and preterm birth or low birth weight between non-Hispanic Black and non-Hispanic White individuals.

Conversely, the policy was linked to a 0.6% decrease in the probability of short-interval birth and a 27-day increase in days to next birth among non-Hispanic Black individuals.

The policy was also associated with a significant decrease in the probability of a subsequent birth within 4 years. “But confidence in this finding is somewhat attenuated by nonparallel trends for this outcome before the policy change,” Steenland told Contemporary OB/GYN®.

The main results of the study do not surprise Steenland because “there are several ways that immediate postpartum LARC could reduce preterm births and low birth weight, such as fewer births overall, fewer short interval births and fewer unintended births.”

The findings of the study are more relevant to policy than to clinical decision-making, according to Steenland, because outcomes of the study were measured among all people who gave birth in a given time period and may be driven by a decrease in the percentage of people who have another birth.

“Future studies examining the effect of waiting 24 months compared to 12 months on infant health, for example, could inform individual decision-making about birth spacing,” she said.

Steenland would like to see policy efforts that expand access to all methods of contraception, including after childbirth hospitalizations though Medicaid expansion, in remaining non-expansion states; maintain federal funding for family planning through Title X; and remove state-level policies that restrict funding to safety-net family planning providers like Planned Parenthood.

“It is also important that immediate postpartum LARC policy implementation be patient-centered and antiracist, so that contraceptive autonomy is not compromised,” said Steenland, who noted that large racial disparities in infant outcomes continue in South Carolina and nationwide.

Reference

1. Steenland MW, Pace LE, Cohen JL. Association of Medicaid reimbursement for immediate postpartum long-acting reversible contraception with infant birth outcomes. JAMA Pediatr. Published online January 10, 2022. doi:10.1001/jamapediatrics.2021.5688