Implementation of Immediate Postpartum Long-Acting Reversible Contraception: Strategies for Success

Over the past few years, there has been growing interest in increasing access to long-acting reversible contraceptives (LARCs), particularly during the postpartum period. Postpartum LARC utilization is safe and effective, has been shown to reduce rapid and repeat unintended pregnancy, and national organizations such as the American College of Obstetrics and Gynecology supports its routine use. ^{1 –3} Forty states now have guidance or policies allowing for Medicaid reimbursement for a LARC device inserted at the time of delivery, ⁴ and utilization of postpartum LARC is on the upswing. ⁵ Although use of postpartum LARC has been shown to be a successful tool in combating unintended pregnancy, and its practice is widely supported, implementation of policies allowing its use has been challenging. At the hospital level, involving stakeholders in all relevant departments and at all administrative levels has been shown to be key in this process. ⁶ In this issue of the Journal of Women's Health, Kroelinger et al. ⁷ identify strategies that can be used at both the hospital and state level to increase access to immediate postpartum LARC.

The authors wisely utilized a framework of implementation science to evaluate the success that these 13 states had in implementing postpartum LARC policies. ⁷ Although clinical research can tell us whether or not an intervention, drug, device, etc., can be of benefit, it is implementation science that investigates not only how to incorporate a new clinical finding into practice, but also how to develop a sustainable model for its use. Implementation science gets to the deeper issues of how to develop and implement policies and helps both individuals and health care systems translate research findings into clinical practice and policies. Employing this framework as it applies to implementation of postpartum LARC programs is critical for their success.

Kroelinger et al. ⁷ investigated various implementation strategies that 13 states spanning the country, from Massachusetts to Texas to Indiana to Montana, utilized in rolling out postpartum LARC policies. Through the development of an “Immediate Postpartum LARC Learning Collective,” they uncovered eight main domains that states identified as key in implementing postpartum LARC policies—provider training, stakeholder partnerships, outreach, pay streams and reimbursement, data/monitoring/evaluation, stocking and supply of devices, service locations, and informed consent. All states identified provider training and stakeholder partnerships as being key in implementing policies; stakeholder partnerships were identified as being critical to successful implementation. The majority of states also identified issues within the domains of outreach; pay streams and reimbursement; and data, monitoring, and evaluation as critical to their success. Provider training and stakeholder partnerships were cross-cutting domains in all 13 states. Stakeholder partnerships were “a critical component required to implement strategies in all other domains.” ⁷ Strategies that were identified as helpful in provider trainings included hands-on training, resources for billing and coding, and identification of clinical champions or physician partners, among others.

Time and again, the need for clinical champions in the successful implementation of postpartum LARC programs has been documented. ^6,8,9 In the study published in this month's issue, clinical champions were found to be vital not only at the hospital level but also at the state level, and were the “driving force … behind implementation.” ⁷ In addition to the known domain of hospital-based implementation, clinical champions at the state level were necessary in moving postpartum LARC policies forward in 11 out of the 13 domains—the only 2 domains in which they were not vital were data, monitoring, and evaluation, and informed consent.

The clinical evidence overwhelmingly supports the use of immediate postpartum LARC, and 80% of states have published guidelines for reimbursement, yet hospitals continue to struggle to offer this vital service. The domains laid out by Kroelinger et al. ⁷ offer a roadmap for institutions looking for strategies to engage stakeholders at both the hospital and state levels, and highlight the importance of buy-in at all levels.