Effect of Increased Provider Payments for Provision of Immediate Postpartum Long-Acting Reversible Contraception: Evidence from South Carolina’s Medicaid Policy Change

Background: Short interpregnancy intervals and unintended pregnancy are associated with adverse neonatal health outcomes. With failure rates of < 1%, long acting reversible contraception (LARC) can facilitate safe pregnancy intervals. Despite this, historically neither public nor private payers have reimbursed hospitals for immediate postpartum LARC and fewer than 1% of women adopt a LARC method in the first month after delivery. This study examines the effect of South Carolina Medicaid’s 2012 policy change to begin providing reimbursement for immediate postpartum LARC separate from the global labor and delivery payment.

Methods: We created a dataset that included inpatient claims for all Medicaid-covered births between 2010 – 2017 in South Carolina (n=242,979) linked to outpatient claims for contraception in the eight weeks after delivery. We used an interrupted time series analysis to test whether Medicaid’s policy affected trends in immediate postpartum LARC provision, provision of other forms of inpatient and outpatient postpartum contraception, and short birth intervals (< 18 months). All analysis was stratified by age group (i.e. teens and adult women). We also estimate the change from expected in each outcome at the end of the study period by calculating the difference between the value of the outcome under the counterfactual post-policy trend and the predicted value of the observed outcome during the last month in the study period.

Results: Few women received an immediate postpartum LARC before Medicaid’s LARC reimbursement policy change. The policy change increased the probability of immediate postpartum LARC provision by 0.098 percentage points (95% CI: 0.076, 0.120) each month for teens and by 0.067 (95% CI: 0.058, 0.076) for adults. By the end of the study period (December 2017), the policy change led to a 5-percentage point higher rate (95% CI, 4.361, 5.683) of LARC use among adults and a 7.9 percentage point higher rate (95% CI, 6.853, 8.914) of LARC use among teens than would be expected in the absence of the policy change. At the start of the study period, roughly 5.1% of adult women and 7.8% of teens having a childbirth covered by Medicaid went on to have another birth within 18 months. The policy decreased the probability of subsequent childbirth within 18 months of delivery among teens by 0.072 percentage points (95% CI: -0.132, -0.011) per month but had no significant effect on the probability of short birth intervals among adult women. By June 2016, the policy had decreased the percent of teens having a short-interval birth by 3.9 percentage points (95% CI, -8.026, 0.261) from what would be expected in the absence of the policy. No statistically significant changes in postpartum use of other contraceptive methods were found among teens, but among adult women the policy decreased postpartum sterilization (-0.125, 95% CI: -0.169, -0.081), and to a lesser degree, contraceptive injectable or pill use (-0.088, 95% CI: -0.159, -0.017).

Conclusions: Medicaid payment policy changes that provide reimbursement for immediate postpartum LARC provision can be an effective policy option to increase immediate postpartum LARC initiation and increase birth spacing among young women.