Informing Policy Change: A Study of Rapid Repeat Pregnancy in Adolescents to Increase Access to Immediate Postpartum Contraception

Introduction

Rapid repeat pregnancy (RRP), defined as an interpregnancy interval of 18 months or fewer between a previous delivery and conception of the subsequent pregnancy, is associated with adverse maternal and neonatal outcomes, including obstetrical complications, preterm delivery, and infant mortality. ¹ In Indiana, 17.1% of adolescents aged 15–19 years have RRP within 12 months and 22.5% have RRP within 18 months after delivery. ² Effective interventions to decrease RRP rate is essential for this high-risk group.

Although postpartum contraception traditionally was provided at the postpartum visit (e.g., 4–6 weeks after the delivery), low attendance rates for adolescents has led to studies focusing on provision before hospital discharge. ^3,4 These studies have found that providing contraception, specifically access to long-acting reversible contraception (LARC) methods, such as the etonogestrel (ENG) contraceptive implant, before hospital discharge can increase utilization and decrease RRP rates. ^{4 –8}

Despite this evidence, the implementation of immediate postpartum LARC presents its own challenges. Given the global reimbursement for obstetrical care, bundling of other inpatient procedures and the cost of stocking devices can be cost- prohibitive for hospitals. ^9,10 This logistical barrier was preventing patients in our state from accessing LARC methods before hospital discharge.

Our primary objective was to determine state-specific RRP rates for adolescents based on chosen postpartum contraception to inform policy change. We hypothesized that adolescents with access to immediate postpartum contraception, in particular the ENG contraceptive implant, would have lower RRP rates compared with other groups. Access to ENG contraceptive implant was prioritized given the preference of this LARC method in the adolescent population. ^{4 –8}

Methods

Results

Of the 330 charts that were identified initially with inclusion criteria, 277 adolescents had complete prenatal and postpartum information and were included in the final analysis. More than half of the patients left the hospital without any form of contraception (54.5%). However, 9.7% of patients received an immediate postpartum ENG contraceptive implant, and 19.1% received Depo injection before hospital discharge. The remainder received a prescription for a short-acting method such as oral contraceptive pills, vaginal ring, patch, or reported they would use barrier methods such as condoms (16.7%).

The overall RRP in our study population was 28.5% (79/277). RRP rates were 3.7% (1/27) for those who received an immediate postpartum ENG contraceptive implant, 22.6% (12/53) for those who received immediate postpartum depo-medroxyprogesterone acetate (DMPA) injection, 39.1% (18/46) for those who received a short-acting or barrier method, and 31.8% (48/151) for those who received no contraception or did not have a documented method (p = 0.01) (Fig. 1).

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FIG. 1.

Outcomes by contraceptive method. DMPA, depo-medroxyprogesterone acetate; ENG, etonogestrel; RRP, rapid repeat pregnancy.

In the multivariable model, the association of RRP with contraception method remained statistically significant (p = 0.01) even after controlling for age, gravidity, and postpartum visit attendance. Variables significantly associated with a higher RRP rate included having a previous abortion (p = 0.03) or pregnancy (p < 0.01), living children (p = 0.05), older age (p ≤ 0.01), and attendance at postpartum visit (p ≤ 0.01) (Table 1). The odds of RRP for patients who do not receive any contraception were 11 times higher than those who received ENG contraceptive implant before hospital discharge (adjusted odds ratio [aOR] = 11.8, 95% confidence interval [CI]: 2.74–110.3). In comparison, the odds ratio for RRP for no method compared with DMPA was aOR = 2.41 (95% CI: 1.13–5.44) and compared with short-acting or barrier methods was aOR = 1.29 (95% CI: 0.60–2.80).

Only one adolescent had the ENG contraceptive implant removed (for breakthrough bleeding) during the 18-month study period, which resulted in an RRP. There was no difference in subsequent induced abortion rates between the groups (p = 0.73), and no abortions documented in the ENG contraceptive implant group.

Discussion

This study demonstrates that patients who received an immediate postpartum ENG contraceptive implant had lower RRP rates than patients who did not. This result is consistent with growing evidence that the provision of immediate postpartum ENG contraceptive implant is essential in decreasing RRP, especially in adolescents. ^7,14 Although previous studies have published evidence to support this intervention, local policy makers were interested in from within our state and among their constituents to show the benefits. The importance of research informing policy has been discussed and is more relevant now that larger pools of data within specific health care systems are available. ¹⁵ Our study highlights the importance of providing specific local data to augment published literature and impact local policy.

There are limitations in our study. Adolescents could have obtained care outside of the INPC or Planned Parenthood network, and we may have missed subsequent pregnancies, including spontaneous abortions, and intended pregnancies. Furthermore, there was no way to confirm sustained use of any method during the study period and the rate of removal for ENG contraceptive implant was low compared with other published data, which could suggest removal happened outside of our clinical data network. The low rates of RRP in the ENG contraceptive implant group led to wide CIs, although we did use a small-sample bias correction. Finally, immediate postpartum contraception was determined by chart review, and we did not verify prescriptions for short-acting methods or patient adherence.

Data from this study were presented to the Indiana Medicaid Medical Advisory Cabinet in 2014. This interdisciplinary team of clinicians and researchers was created in 2006 to provide research-based policy advice to the Indiana Office of Medicaid Policy and Planning. Given the strong evidence that LARC, specifically the ENG contraceptive implant, was effective in preventing adolescent RRP in our state, the recommendation was to uncouple these payments to increase LARC access for all women after childbirth. This insurance reimbursement policy change took effect in 2015 and was further expanded to some private insurers within the state. At the time of our study conception in 2012, only 1 state Medicaid plan had published policies regarding immediate postpartum LARC placement and now there are 40 states with such policies. ¹⁶ The importance of providing specific local data to augment published literature and impact local policy was critical.

Our study reaffirms that immediate postpartum placement of the ENG contraceptive implant is effective in preventing RRP in adolescents. Furthermore, we demonstrate how research can lead to state-wide insurance policy change that provided access to all LARC methods for women in our state before hospital discharge. The importance of partnerships between policy makers, public health officials, clinicians, and researchers is integral to assuring that policy is reflective and responsive to recent and local evidence. These partnerships are vital as efforts continue to assure all women are able to access the contraception they desire. Following this policy change, next steps include assuring that implementation and improvements to access are realized.