After delivering a 17-year-old girl’s second baby, certified nurse midwife Olivia Kroening-Roche walked the patient — who she said suffered physically, socially and economically from being a teenage parent — to a nearby clinic so she could receive a birth control implant.
In an email to Oregon Medicaid officials, Kroening-Roche wrote that the girl had not received a highly effective form of contraceptive following her first delivery, and she wanted to make sure she did this time. She was writing to express support for a policy being considered that would reimburse providers for placing contraceptives immediately after women give birth or have abortions.
“It is hard to imagine why this would not be enacted,” wrote Kroening-Roche, who works at Women’s Healthcare Associates in Tualatin.
Oregon’s Medicaid program, called the Oregon Health Plan, already covers so-called intrauterine devices, contraceptives that providers place into the uterus, and contraceptive implants, which providers place under the skin. Relatively few women use them, however, despite lots of evidence showing they work.
Most providers don’t place the contraceptives until follow-up visits weeks or months after deliveries. In many cases, that’s because the state Medicaid program pays hospitals a lump sum for deliveries, but that doesn’t include contraceptives. That leaves the chance that a women could become pregnant before her follow-up visit.
On top of that, lots of women miss the follow-up visit altogether, said Dr. Catherine Livingston, associate medical director of Oregon’s Health Evidence Review Commission, the group that determines what’s covered under OHP. Plenty of factors keep women from the appointments: money, a loss of insurance or a lack of transportation or child care, she said.
“They could become pregnant immediately, or they just may never make it into their follow-up visit and they may get pregnant six months later, just because they never had the opportunity to obtain effective contraception,” Livingston said.
The Centers for Medicare and Medicaid Services sent out a notice to states in April urging them to cover IUDs and implants immediately following births. Oregon had already been considering the new policy when that notice came out, Livingston said.
Riskier, but worth it?
The new policy, however, would be unlikely to change much in Central Oregon if it’s approved. That’s because it’s not the lack of reimbursement that prevents local providers from placing IUDs after birth, it’s the risk that they’ll become dislodged from the uterus.
The uterus is a muscle that’s large and stretched out after giving birth, said Dr. Barbara Newman, medical director for St. Charles Health System’s Center for Women’s Health in Redmond. It contracts as it returns to its normal size.
“Those contractions also aid in pushing out a foreign body — in this case, an IUD,” she said.
While there’s not a wealth of research comparing the risk of expulsion — as doctors call it — when IUDs are placed immediately after birth and weeks or months later, the studies that do exist show the former carries a higher risk.
A 2010 study found the devices fell out within six months in 12 out of 50 women who had them placed immediately postpartum compared with two out of 46 women who received them six to eight weeks after giving birth. The study, published in the journal Obstetrics & Gynecology, found that placing IUDs right after delivery carries a 24 percent expulsion rate, compared with 4.4 percent if there is a delay.
A 2015 Cochrane Collaboration report analyzed all existing research — 15 studies — comparing the expulsion rate between IUDs placed immediately postpartum and following a delay. After six months, the group concluded that while more women in immediate placement groups had experienced expulsion, that group had an overall higher rate of IUD use compared to delayed placement groups.
The Cochrane report concluded that the benefit of immediate placement may outweigh the higher risk of expulsion. Further, postpartum follow-up visits can help detect expulsion, as can teaching women about the symptoms.
That was the same conclusion drawn by Oregon’s Health Evidence Review Commission in its draft guidance proposing to cover IUDs and implants directly postpartum. The commission also cited research that found the practice saves money by avoiding unintended pregnancies.
The commission cited a 2015 National Committee for Quality Assurance statistic that found 62 percent of women relying on government insurance programs such as Medicaid attended their postpartum checkups in 2014.
At St. Charles, however, Newman said that rate is much higher: 78 percent of patients attend their six-week follow-up visit. She attributed that to the health system’s practice of having behavioral health providers keep in contact with patients.
“There is a bond that develops,” she said.
Livingston, with the commission, said 78 percent seems “unusually high” compared with published literature.
“But I would also say that means that 22 percent of women who may have wanted effective LARC contraception would not have obtained it, and a significant proportion of them could end up with unintended pregnancies,” she said.
Newman said St. Charles providers talk to patients about their risk for unintended pregnancies between delivery and the six-week postpartum visit.
“We do recommend for them for their own health and for the health of another pregnancy that they not get pregnant within that time,” she said.
‘Why would I go back?’
In 2012, South Carolina became the first state whose Medicaid program covered IUDs and implants immediately following delivery.
Like in other states, women in South Carolina just weren’t coming back for their follow-up visits, which caused the use of IUDs and implants to be low, said Deborah Billings, director of Choose Well SC, a group that educates women about birth control and helps reduce barriers to access. Sometimes that was because they couldn’t get out of work, sometimes they couldn’t find child care.
Or, “just feeling OK. I feel good. I feel fine, so I’m not going to go back,” Billings said. “Why would I go back?”
Billings helped compile a January toolkit on the subject to help hospitals implement the state’s policy. So far, 19 state Medicaid programs have adopted policies that reimburse for IUDs and implants immediately postpartum, according to the report.
In South Carolina, Medicaid reimburses providers for the birth control — both the device and the insertion — separately from the delivery, Billings said.
Oregon hasn’t yet decided how it would reimburse, but it would likely be a separate payment as well, Livingston said.
Dozens of providers emailed the commission in June and July expressing support for the proposed change, which the commission could approve as early as October.
Dr. Rita Sharshiner, an obstetrician with Oregon Health and Science University, wrote that she works with underserved populations and sees firsthand the consequences of not providing essential services to those who need it most.
“Unintended pregnancies can occur as early as 3 to 4 weeks postpartum, long before most women present for their postpartum clinic visit,” she wrote, adding that such short interval pregnancies are associated with a higher risk of preterm birth and other complications.
Some of the providers, however, said it’s important that the same coverage be available to women who rely on Citizen Alien Waived Emergent Medical, a program that provides health care for low-income, undocumented individuals in emergency situations, including pregnancy, since that coverage ends before a follow-up visit. Livingston said the commission is aware and exploring the issue.