Postpartum long-acting reversible contraceptive adoption after a statewide initiative.

OBJECTIVES: To examine the effects of a comprehensive, multiyear (2015-2020) statewide contraceptive access intervention in Delaware on the contraceptive initiation of postpartum Medicaid patients. The program aimed to increase access to all contraceptives, including long-acting reversible contraceptives (LARC). The program included interventions specifically targeting postpartum patients (Medicaid payment reform and hospital-based immediate postpartum (IPP) LARC training) and interventions in outpatient settings (provider training and operational supports). DATA SOURCES AND STUDY SETTING: We used Medicaid claims data between 2012 and 2019, from Delaware and Maryland (a comparison state), to identify births and postpartum contraceptive methods up to 60 days postpartum among patients aged 15-44 years who were covered in a full-benefit eligibility category. STUDY DESIGN: Using difference-in-differences, we assessed changes in LARC, tubal ligation, and short-acting methods (oral contraceptive, injectable, patch/ring). LARC rates were assessed at 60 days after delivery and on an immediate postpartum basis. Other methods were only assessed at 60 days. Analyses were conducted separately for an early-adopting high-capacity hospital (that delivers approximately half of all Medicaid financed births) and for all other later-adopting hospitals in the state. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from administrative claims. PRINCIPAL FINDINGS: The program increased postpartum LARC insertions by 60 days after delivery by 11.7 percentage points (95% CI: 10.7, 12.8) in the early-adopting hospital and 6.9 percentage points (95% CI: 4.8, 5.9) in later-adopting hospitals. Increases in IPP versus outpatient LARC drove the change, but we did not find evidence that IPP crowded-out outpatient LARC services. We observed decreases in short-acting methods, suggesting substitution between methods, but the share of patients with any method increased at the early-adopting hospital (5.2 percentage points; 95% CI: 3.5, 6.9) and was not statistically significantly different at the later-adopting hospitals. CONCLUSIONS: Direct reimbursement for IPP LARC, in combination with provider training, had a meaningful impact on the share of Medicaid-enrolled postpartum women with LARC claims.

LGBTQ+ Youth Homelessness in Delaware:: Building a Case for Targeted Surveillance and Assessment of LGBTQ+ Youth Needs and Experiences.

Objective: In this article, we examine the issue of LGBTQ+ youth homelessness in Delaware, summarize current services available and prior research work that has been done, examining the number, needs, and experiences of unaccompanied unhoused LGBTQ+ youth. Methods: We provide a literature review detailing risks associated with LGBTQ+ youth homelessness, resources available, and prior studies and surveys examining this population. Results: LGBTQ+ youth experiencing homelessness are particularly vulnerable to physical and mental health challenges, abuse, and violence. The unique needs of this population necessitate specialized resources, yet there are a limited number of such resources available in Delaware and a dearth of information on youth homelessness in general, including LGBTQ+ youth. For example, administrative barriers exist for unaccompanied queer youth seeking shelter services, such as need for legal identification or being grouped in shelter populations based on sex assigned at birth rather than gender identity. Exposure to unsafe environments is a general problem for queer youth. This can make public spaces feel unsafe and increase risk of physical or mental harm, mistreatment, or abuse when seeking shelter outside of agency services and resources. In order to accurately identify and appropriately serve this population, additional research is necessary. Conclusions: Evidence building is a critical first step in creating an effective study to examine the issue of LGBTQ+ youth homelessness in Delaware. With the evidence acquired in our literature review our next step to establish an informed methodology is to hold service provider and LGBTQ+ lived experience focus groups. Through a qualitative approach we aim to learn how to appropriately utilize the quantitative tools identified in our analysis and to assess what questions are missing to advance the needs of this population.

Same-day long-acting reversible contraceptive utilization after a statewide contraceptive access initiative.

BACKGROUND: Same-day placement of long-acting reversible contraceptives, occurring when the device is requested and placed within a single visit, reduces barriers to the patient and reduces unintended pregnancies. Despite the safety and efficacy of same-day placement, access to same-day services remains low. OBJECTIVE: This study aimed to evaluate the effects of the Delaware Contraceptive Access Now initiative, a statewide initiative in Delaware focused on increasing same-day access to effective contraception on same-day receipt of long-acting reversible contraceptives. STUDY DESIGN: We used Medicaid claims and encounter data to identify instances of same-day and multivisit receipts of long-acting reversible contraceptives among Medicaid-enrolled individuals in Delaware and Maryland aged 15-44 years who were covered in a full-benefits or family planning Medicaid aid category during the month of the placement and the 2 previous months. We used a difference-in-differences design that compared changes in the outcome from before to after implementation of the initiative among placements at agencies that participated in the initiative (n=6676) vs 2 alternative comparison groups: placements at Delaware agencies that did not participate (n=688) and placements in Maryland (n=35,847). RESULTS: We found that the intervention was associated with a 13.3 percentage point increase (95% confidence interval, 1.9%-24.7%) in receipt of same-day long-acting reversible contraceptives using a nonparticipating Delaware comparison group, a 21.1 percentage point increase (95% confidence interval, 13.7%-28.6%) using a Maryland comparison group, and a 21.0 percentage point increase (95% confidence interval, 14.1%-27.9%) using a pooled comparison group. The effects were larger for implants than intrauterine devices. CONCLUSION: The Delaware Contraceptive Access Now initiative substantially increased the number of patients receiving long-acting reversible contraceptives through a single-visit encounter. Our findings suggested that coordinated interventions involving provider and staff training and capital investments that seed device stocking can increase the number of patients receiving same-day long-acting reversible contraceptives.

Delaware Contraceptive Access Now and Contraceptive Initiation Among Medicaid Enrollees, 2015‒2020.

Delaware Contraceptive Access Now was a statewide contraceptive access program implemented in Delaware between 2015 and 2020. We evaluated the association of the program with contraceptive initiation in Delaware's Medicaid program using a difference-in-differences design that compared changes in Delaware to changes in Maryland. Results suggest that program implementation was associated with increased initiation of long-acting reversible methods, particularly among adolescent patients aged 15 to 18 years. We found less-consistent evidence for changes to any contraceptive method. (Am J Public Health. 2022;112(S5):S537-S540. https://doi.org/10.2105/AJPH.2022.306938).

Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population.

OBJECTIVE: To evaluate the likelihood of a short interpregnancy interval (IPI) resulting in a birth among women covered by Medicaid, as a function of postpartum contraceptive method type. STUDY DESIGN: We used Medicaid claims and eligibility data to identify women (aged 15-44) who had a Medicaid-financed birth in Delaware in the years 2012-2014 (n = 10,328). Claims were analyzed to determine postpartum contraceptive type within 60 days of the index birth, and linked birth certificates were used to determine the incidence and timing of a subsequent birth through 2018 (regardless of payer). We used logistic regression to analyze the likelihood of having a short IPI following the index birth as a function of postpartum contraceptive type, controlling for preterm births, parity, having a postpartum checkup, and maternal characteristics including age, race, education, and marital status. RESULTS: Compared to patients receiving postpartum long-acting reversible contraceptive methods (LARC), patients with no contraceptive claims had nearly 5 times higher odds (odds ratio [OR] = 4.98, confidence interval [CI] = 3.05-8.13) and those with claims for moderately effective methods (injectable, pill, patch, or ring) had 3.5 times higher odds (OR = 3.51, CI = 2.13-5.77) of a subsequent birth following a short IPI. CONCLUSIONS: In a state population of Medicaid-enrolled women, women with claims for postpartum LARC had substantially lower risk of a short IPI resulting in a birth. IMPLICATIONS: Women who received LARC within 60 days postpartum are less likely to experience a short interpregnancy interval resulting in a birth. The evidence suggests that recent state policy changes that make postpartum LARC more accessible to those that desire it will be an effective strategy in helping patients obtain desired birth intervals.