Multilevel Barriers to Long-Acting Reversible Contraceptive Uptake: A Narrative Review.

Unintended pregnancies, which occur in almost half (45%) of all pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives (LARCs), namely intrauterine devices and implants. Although LARCs are highly acceptable to women at risk of unintended pregnancies, barriers to accessing LARCs hinder its uptake. These barriers are greater among racial and socioeconomic lines and persist within and across the intrapersonal, interpersonal, institutional, and policy levels. A synthesis of these barriers is unavailable in the current literature but would be beneficial to health care providers of reproductive-aged women, clinical managers, and policymakers seeking to provide equitable reproductive health care services. The aim of this narrative review was to aggregate these complex and overlapping barriers into a concise document that examines: (a) patient, provider, clinic, and policy factors associated with LARC access among populations at risk of unintended pregnancy and (b) the clinical implications of mitigating these barriers to provide equitable reproductive health care services. This review outlines numerous barriers to LARC uptake across multiple levels and demonstrates that LARC uptake is possible when the woman is informed of her contraceptive choices and when financial and clinical barriers are minimized. Equitable reproductive health care services entail unbiased counseling, a full range of contraceptive options, and patient autonomy in contraceptive choice.

Long-acting reversible contraceptive utilization after policy change increasing device reimbursement to wholesale acquisition cost in Louisiana.

BACKGROUND: Unintended pregnancies, occurring in nearly 1 out of every 2 (45%) pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives, namely intrauterine devices and implants. Inadequate reimbursement for long-acting reversible contraceptive devices may be an access barrier to long-acting reversible contraceptive uptake. In 2014, the Louisiana Department of Health Bureau of Health Services Financing implemented a policy change that increased the Medicaid reimbursement rates for acquiring long-acting reversible contraceptive devices to the wholesale acquisition cost. OBJECTIVE: To examine the association of a Medicaid policy change that increased the long-acting reversible contraceptive device reimbursement rate to the wholesale acquisition cost (ie, price set by the manufacturers) on long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. MATERIALS AND METHODS: This retrospective, repeated cross-sectional study used 2013-2015 Louisiana Medicaid claims data and contraceptive provision measures to assess associations between patient (age, race, urban/rural residence, postpartum status) and provider (urban/rural location, specialty) characteristics and long-acting reversible contraceptive uptake among contraceptive users (N = 193,623) using bivariate and logistic regression analyses. RESULTS: After long-acting reversible contraceptive reimbursement increased, there was a 2-fold likelihood increase in use in 2015 vs 2013 (odds ratio, 2.08; 95% confidence interval, 1.69-2.55). Long-acting reversible contraceptive uptake was more likely across all patient and provider subgroups in 2015 vs 2013 but notably among patients receiving contraceptive care from family planning clinics (odds ratio, 3.93; 95% confidence interval, 2.34-6.62). CONCLUSION: Removal of a provider-level financial barrier to long-acting reversible contraceptive provision was associated with increased long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. Efforts to improve long-acting reversible contraceptive access should focus on equitable healthcare reimbursement for healthcare providers of reproductive-aged women.

The MCH navigator: tools for MCH workforce development and lifelong learning.

Maternal and child health (MCH) leadership requires an understanding of MCH populations and systems as well as continuous pursuit of new knowledge and skills. This paper describes the development, structure, and implementation of the MCH Navigator, a web-based portal for ongoing education and training for a diverse MCH workforce. Early development of the portal focused on organizing high quality, free, web-based learning opportunities that support established learning competencies without duplicating existing resources. An academic-practice workgroup developed a conceptual model based on the MCH Leadership Competencies, the Core Competencies for Public Health Professionals, and a structured review of MCH job responsibilities. The workgroup used a multi-step process to cull the hundreds of relevant, but widely scattered, trainings and select those most valuable for the primary target audiences of state and local MCH professionals and programs. The MCH Navigator now features 248 learning opportunities, with additional tools to support their use. Formative assessment findings indicate that the portal is widely used and valued by its primary audiences, and promotes both an individual's professional development and an organizational culture of continuous learning. Professionals in practice and academic settings are using the MCH Navigator for orientation of new staff and advisors, "just in time" training for specific job functions, creating individualized professional development plans, and supplementing course content. To achieve its intended impact and ensure the timeliness and quality of the Navigator's content and functions, the MCH Navigator will need to be sustained through ongoing partnership with state and local MCH professionals and the MCH academic community.

Psychosocial predictors of being an underweight infant differ by racial group: a prospective study of Louisiana WIC program participants.

OBJECTIVES: In order to prospectively identify psychosocial predictors of infants being underweight, we followed 3,302 low-income infants. These infants received well-baby care in health departments and were enrolled in the Women, Infants, and Children (WIC) Supplemental Food Program from the newborn period to 12 months of age. METHODS: We linked risk factor data collected from newborn medical history records to anthropometric data from a WIC database. The unadjusted relative risk of being underweight at 12 months of age, defined as weight for recumbent length below the 5th percentile, according to current Centers for Disease Control and Prevention growth charts, for each group was calculated for the study population and for black and white racial groups. Using logistic regression, we calculated odds ratios measuring the effect of the newborn risk factors on underweight status at 12 months of age. RESULTS: There were no psychosocial risk factors that were significantly associated with being underweight simultaneously in both racial groups. Among black infants, those whose mothers had an eighth grade education or lower were at greater risk of being underweight at 12 months of age (OR=3.7, CI=1.5-4.8), as were those whose mothers were married (OR=2.7, CI=1.5-4.8). Among white infants, those whose mothers initiated prenatal care in the third trimester were significantly more likely to have underweight infants at 12 months of age (OR=4.5, CI=1.6-12.4). CONCLUSIONS: Predictors of being underweight at 12 months of age in a low-income population differ by racial group. Further research of public health interventions targeting families of infants with the significant psychosocial risk factors is needed.

Birth weight and infant growth: optimal infant weight gain versus optimal infant weight.

OBJECTIVE: Infant growth assessment often focuses on "optimal" infant weights and lengths at specific ages, while de-emphasizing infant weight gain. Objective of this study was to examine infant growth patterns by measuring infant weight gain relative to birth weight. METHODS: We conducted this study based on data collected in a prospective cohort study including 3,302 births with follow up examinations of infants between the ages of 8 and 18 months. All infants were participants in the Louisiana State Women, Infant and Children Supplemental Food Program between 1999 and 2001. Growth was assessed by infant weight gain percentage (IWG%, defined as infant weight gain divided by birth weight) as well as by mean z-scores and percentiles for weight-for-age, length-for-age, and weight-for-length calculated based on growth charts published by the U.S. Centers for Disease Control (CDC). RESULTS: An inverse relationship was noted between birth weight category and IWG% (from 613.9% for infants with birth weights <1500 g to 151.3% for infants with birth weights of 4000 g or more). In contrast, low birth weight infants had lower weight-for-age, weight-for-length z-scores and percentiles compared to normal birth weight infants according to CDC growth charts. CONCLUSIONS: Although low birth weight infants had lower anthropometric measures compared to a national reference population, they had significant catch-up growth; High birth weight infants had significant slow-down growth. We suggest that growth assessments should compare infants' anthropometric data to their own previous growth measures as well as to a reference population. Further studies are needed to identify optimal ranges of infant weight gain.