Improving Access to Immediate Postpartum Long-Acting Reversible Contraception

Background In 2019, nearly half of the pregnancies in the United States were unintended.[1] We know that pregnancy spacing is important for healthy families. The optimal interval between delivery and subsequent pregnancy is at least 18 months. The risk of low birth weight and preterm birth is highest with short interval pregnancies with an interval of less than 6 months.[2] Non-breastfeeding women can ovulate as early as 25 days postpartum, 40% will ovulate by 6 weeks postpartum, and 57% of women are sexually active by 6 weeks postpartum.[3] This data indicates that it is possible for someone to conceive about 3 weeks after delivery which is even before most people have their first postpartum follow-up visit. For many patients, their hospital visit for their delivery is an ideal opportunity to access long-acting reversible contraception. This phase of care represents a time when patients are most likely to have access to a provider who can administer LARC. Offering immediate postpartum long-acting reversible contraception (IPP LARC) facilitates access to safe, effective contraception. IPP LARC refers to placement of an intrauterine device (IUD) after placental delivery and placement of a Nexplanon implant during postpartum hospitalization. Many patients are unable to adhere to postpartum follow-up visits for a variety of reasons including childcare obligations, inability to get time off of work, unstable housing, lack of transportation, communication or language barriers, and lack of insurance coverage or potential expiration of Medicaid eligibility to name a few. The average rate of postpartum visit attendance in the United States is 72%; a significant portion of women do not attend a postpartum follow-up visits.[3] Offering IPP LARC can reduce unintended pregnancy and lengthen interpregnancy intervals, thereby promoting the health, wellness, and safety of our patients. Objectives Providing access to IPP LARC helps to ensure our patients have access to contraceptive methods at every interaction with the healthcare system in order to maximize reproductive autonomy and control of individual family planning. The passage of assembly bill 2129 (AB 2129), which was enacted on January 1, 2025, requires health insurance in California to reimburse for devices, implants, and professional services associated with IPP LARC for deliveries that take place in a general acute care hospital or licensed birth center. Lack of guaranteed reimbursement and accurate billing tools for IPP LARC were previously a significant barrier of access to this care. Therefore, this study will investigate the change in absolute number and frequency of IPP LARCs administered before and after both the implementation of AB 2129 and the implementation of billing coding revisions to assess the efficacy of this legislation to improve access to care for LARCs. Methods This study is a quality improvement data analysis that looked at IPP LARC administration before and after both the implementation of AB 2129 and the implementation of billing coding revisions. The absolute number of LARCs administered and the percentage of deliveries after which IPP LARC was administered were calculated as metrics of IPP LARC usage. One-tailed t-tests were calculated. Results In the 13 months before AB 2129 took effect, 156 IPP LARCs were administered, consistent with a rate of 12 IPP LARCs per month accounting for 9% of deliveries. In the 1 year and 5 months after AB2129 took effect, 217 IPP LARCs were administered, consistent with a rate of 13 IPP LARCs per month accounting for 8% of deliveries. In the 23 months before the billing coding revisions were implemented, 284 IPP LARCs were administered, consistent with a rate of 12 IPP LARCs per month accounting for 9% of deliveries. In the 7 months after billing coding revisions were implemented, 89 IPP LARCs were administered, consistent with a rate of 13 IPP LARCs per month accounting for 8% of deliveries. The range of reimbursement rates for IPP LARC administration before AB2129 or billing coding revisions was 90% to 99% and the range after was 84% to 99%. The p-value for the change in the absolute number of IPP LARCs administered before and after implementation of AB2129 and billing coding revisions was 0.3, 0.4 for the percent of deliveries with IPP LARC administration, and 0.3 for the reimbursement rate. Conclusions Based on currently available data, there is no observable increase in the use of IPP LARC after initiatives to improve access were implemented, including AB2129 and billing coding revisions. Areas for future research include assessment of insurance payor types represented among patients who receive IPP LARC and a longer observation period after implementation of access to care initiatives to observe the impact of the program as awareness spreads and new workflows are better established. One possible reason that no increase in reimbursement rates was observed is because patients with public insurance are highly represented on service at this institution, and public insurance had more established routine for IPP LARC reimbursement compared to private insurance, which helped reduce barriers even before these implemented changes. What we can anecdotally share from our interdisciplinary collaborations and meetings to improve IPP LARC access is that laws are not sufficient to drive practice changes if institutional systems cannot act on them to achieve adequate reimbursement for the practice changes.