Pictured above, from left, Abby Liberty, María Rodriguez, Blair Darney and Kimberly Yee.
Studies show that women who have children closer together – defined by the medical community as 18 months or less – are at higher risk of a broad range of adverse health outcomes for mom and baby.
These poor outcomes include maternal obesity, diabetes, preterm birth, low birth weight, neonatal intensive care admission and infant mortality.
Approximately 38% of these short interpregnancy interval (IPI) births occur among Medicaid enrollees, and over half – 55% – of these pregnancies are unintended, according to data from the National Survey of Family Growth.
“We know that, in cases of these short IPIs, disparities exist across racial and economic lines and may contribute to a multigenerational cycle of inequity,” said physician-scientist and reproductive health researcher Maria Rodriguez, M.D. ’04, R ’08, M.P.H., associate professor of obstetrics and gynecology, OHSU School of Medicine. “Prenatal and postpartum care are key to providing women with tools to prevent and plan future pregnancies through use of contraception.”
South Carolina: a case study
Previous studies have demonstrated that long-acting, reversible contraception (LARC) such as an IUD or implant have nearly four times the odds of achieving an optimal IPI.
“However multiple factors restrict postpartum LARC use,” said Dr. Rodriguez. “For example, by federal law, Medicaid insurance coverage ends at 60 days postpartum. Loss of coverage is a driver of poor attendance at postpartum visits and decreases receipt of contraception.”
States can choose to implement policy that expands access to postpartum contraception, said Dr. Rodriguez. In 2012, South Carolina became the first state to change Medicaid reimbursement policy to allow for the IUD and implant to be placed in the hospital, immediately following childbirth.
“Prior to this policy change, the IUD and implant were only available in the outpatient settings, and many women do not attend postpartum appointments, approximately half in a Medicaid population,” said first author Abigail Liberty, M.D., obstetrics and gynecology resident.
Drs. Rodriguez and Liberty and fellow researchers wanted to understand how a change in Medicaid reimbursement policy affected short IPIs.
The resulting study, “Coverage of immediate postpartum long acting reversible contraception has improved birth intervals for at risk populations,” published in the American Journal of Obstetrics and Gynecology was selected as the School of Medicine’s Paper of the Month. Dr. Liberty, was also a finalist for the School of Medicine Alumni Association 2020 Resident Paper of the Year competition for her work in this study.
“A revealing look”
The team conducted a historical cohort study of live births among Medicaid recipients in South Carolina between 2010 and 2017 – 2 years before and 5 years after the policy change – using birth certificate data linked with Medicaid claims.
By deploying logistic regression models, the researchers characterized trends in long-acting and reversible contraception use and interpregnancy intervals over the study period to 1) test the association of key factors such as rural locations, inadequate prenatal care and medical comorbidities with immediate and outpatient postpartum LARC following the policy change and 2) to test the association of immediate postpartum and postpartum LARC with short interpregnancy interval.
What they found was that, indeed, women with the highest risk of short IPIs benefited from receiving immediate postpartum LARC. Women with medically complex pregnancies and those at the highest risk of loss to care postpartum were significantly more likely to receive LARC prior to leaving the hospital.
“Women receiving LARC prior to leaving the hospital from childbirth were significantly less likely to have a short IPI,” said Dr. Liberty.
She added, “We also found that implementation of the policy has not been even across the state, and that there is a need for further outreach to rural areas.”
“This study provided a revealing look into the challenges of rural medical care,” said Mary Heinricher, Ph.D., associate dean for research, OHSU School of Medicine.
Because the study just came out, it’s too early to say whether its conclusions will improve delivery of reproductive services in rural South Carolina. But the American College of Obstetricians and Gynecologists is leading a national effort to improve implementation of this service, said Dr. Rodriguez.
“I’ve led trainings with them in Oregon and South Carolina, which predates this article,” she explained. “We are continuing to work with rural hospitals to have this be an offered service.”
The team’s analysis is the first publication out of a five-year, NIH-funded project led by Dr. Rodriguez to study how differences in insurance coverage during pregnancy influence disparities in key maternal and newborn outcomes.
Her next line of inquiry will examine whether and in what ways restricting access to care during pregnancy for immigrant women – Emergency Medicaid – perpetuates multigenerational health disparities and increases public costs.
“I’m comparing data from Oregon, where coverage of prenatal and postpartum care is available for all low-income women, regardless of citizenship, with data from South Carolina, where low-income immigrant women only have a hospital admission resulting in childbirth covered,” she said.
“Addressing the widening racial and economic disparities in the U.S.’s maternal mortality crisis requires a thorough understanding of the role structural factors play in driving poor maternal health,” said Dr. Rodriguez. “Medicaid policy is a key – and modifiable – driver of maternal health.”
Liberty A, Yee K, Darney BG, Lopez-defede A, Rodriguez MI, Coverage of immediate postpartum long acting reversible contraception has improved birth intervals for at risk populations, American Journal of Obstetrics and Gynecology (2020), doi: https://doi.org/10.1016/ j.ajog.2019.11.1282.