Preterm Birth and Receipt of Postpartum Contraception Among Women with Medicaid in North Carolina.

OBJECTIVES: To compare receipt of contraception and method effectiveness in the early postpartum period among women with and without a recent preterm birth (PTB). METHODS: We used data from North Carolina birth certificates linked to Medicaid claims. We assessed contraceptive claims with dates of service within 90 days of delivery among a retrospective cohort of women who had a live birth covered by Medicaid between September 2011 and 2012 (n = 58,201). To estimate the odds of receipt of contraception by PTB status (24-36 weeks compared to 37-42 weeks [referent]), we used logistic regression and tested for interaction by parity. To estimate the relationship between PTB and method effectiveness based on the Center for Disease Control and Prevention Levels of Effectiveness of Family Planning Methods (most, moderate and least effective [referent]), we used multinomial logistic regression. RESULTS: Less than half of all women with a live birth covered by Medicaid in North Carolina had a contraceptive claim within 90 days postpartum. Women with a recent PTB had a lower prevalence of contraceptive receipt compared to women with a term birth (45.7% vs. 49.6%). Women who experienced a PTB had a lower odds of receiving contraception. When we stratified by parity, women with a PTB had a lower odds of contraceptive receipt among women with more than two births (0.79, 95% CI 0.74-0.85), but not among women with two births or fewer. One-fourth of women received a most effective method. Women with a preterm birth had a lower odds of receiving a most effective method (0.83, 95% CI 0.77-0.88) compared to women with a term birth. CONCLUSIONS FOR PRACTICE: Contraceptive receipt was low among women with a live birth covered by Medicaid in North Carolina. To optimize contraceptive use among women at risk for subsequent preterm birth, family planning strategies that are responsive to women's priorities and context, including a history of preterm birth, are needed. SIGNIFICANCE: Access to free or affordable highly effective contraception is associated with reductions in preterm birth. Self-report data indicate that women with a very preterm birth (PTB) are less likely to use highly or moderately effective contraception postpartum compared to women delivering at later gestational ages. Using Medicaid claims data, we found that less than half of all women with a Medicaid covered delivery in North Carolina in 2011-2012 had a contraceptive claim within 90 days postpartum, and one fourth received a most effective method. Women with a PTB and more than two children were least likely to receive any method. Family planning strategies that are responsive to women's priorities and context, including a history of preterm birth, are needed so that women may access their contraceptive method of choice in the postpartum period.

Pregnancy Medical Home Care Pathways Improve Quality of Perinatal Care and Birth Outcomes.

The clinical leadership of the Pregnancy Medical Home (PMH) program develops and disseminates clinical pathways to promote evidence-based practice and to improve quality of care and outcomes. PMH pathways represent the first standardized clinical guidance for obstetric providers statewide across all care settings.

Predicting Preterm Birth Among Women Screened by North Carolina's Pregnancy Medical Home Program.

OBJECTIVE: To determine which combination of risk factors from Community Care of North Carolina's (CCNC) Pregnancy Medical Home (PMH) risk screening form was most predictive of preterm birth (PTB) by parity and race/ethnicity. METHODS: This retrospective cohort included pregnant Medicaid patients screened by the PMH program before 24 weeks gestation who delivered a live birth in North Carolina between September 2011-September 2012 (N = 15,428). Data came from CCNC's Case Management Information System, Medicaid claims, and birth certificates. Logistic regression with backward stepwise elimination was used to arrive at the final models. To internally validate the predictive model, we used bootstrapping techniques. RESULTS: The prevalence of PTB was 11 %. Multifetal gestation, a previous PTB, cervical insufficiency, diabetes, renal disease, and hypertension were the strongest risk factors with odds ratios ranging from 2.34 to 10.78. Non-Hispanic black race, underweight, smoking during pregnancy, asthma, other chronic conditions, nulliparity, and a history of a low birth weight infant or fetal death/second trimester loss were additional predictors in the final predictive model. About half of the risk factors prioritized by the PMH program remained in our final model (ROC = 0.66). The odds of PTB associated with food insecurity and obesity differed by parity. The influence of unsafe or unstable housing and short interpregnancy interval on PTB differed by race/ethnicity. CONCLUSIONS: Evaluation of the PMH risk screen provides insight to ensure women at highest risk are prioritized for care management. Using multiple data sources, salient risk factors for PTB were identified, allowing for better-targeted approaches for PTB prevention.

The perinatal quality collaborative of North Carolina's 39 weeks project: a quality improvement program to decrease elective deliveries before 39 weeks of gestation.

BACKGROUND: Despite long-standing guidelines from the American College of Obstetricians and Gynecologists that call for avoiding elective births prior to 39 weeks of gestation, elective deliveries make up almost one-third of US births occurring in weeks 36-38. Poor outcomes are more likely for infants born electively before 39 weeks than for those born at 39 weeks. The Perinatal Quality Collaborative of North Carolina (PQCNC) undertook the 39 Weeks Project in 2009-2010 with the aim of reducing the number of early-term elective deliveries in North Carolina hospitals. METHODS: Participating hospitals (N = 33) provided retrospective data on all early-term deliveries and created new policies, or amended or enforced existing policies, to accomplish the project's goals. Project activities included in-person learning sessions, regional meetings, webinars, electronic newsletters, a secure extranet Web site where participating hospitals could share relevant materials, and individual leadership consultations with hospital teams. Hospitals submitted monthly data to PQCNC, which provided ongoing training and data analysis. RESULTS: Elective deliveries before 39 weeks of gestation decreased 45% over the project period, from 2% to 1.1% of all deliveries. The proportion of elective deliveries among all scheduled early-term deliveries also decreased, from 23.63% to 16.19%. There was an increase in the proportion of patients with documented evidence of medical indications for early delivery, from 62.4% to 88.2%. LIMITATIONS: No data were collected to determine whether outcomes changed for patients whose deliveries were deferred. The project also depended on each hospital to code its own data. CONCLUSION: The PQCNC's 39 Weeks Project successfully decreased the rate of early-term elective deliveries in participating hospitals.