Revitalizing long-acting reversible contraceptives in settings with high unmet need: a multicountry experience matching demand creation and service delivery.

BACKGROUND: Contraception in many developing countries is characterized by high unmet need, irregular access, low utilization and presumed demand for long-acting reversible contraceptives (LARCs). STUDY DESIGN: A 13-country initiative focused on increasing consumer demand and high quality services for intrauterine devices (IUDs) began in 2009. Services were provided through (a) private sector-franchised or affiliated clinics; (b) providers seconded to the public sector and (c) special "event" days. Client intake data are used to compare the profile of IUD acceptors with IUD users from representative national datasets of select countries, as well as examine trends in IUD uptake. RESULTS: During 2009-2010, 575,601 IUDs were inserted across the 13 countries. Compared to national IUD users, users in this project were slightly younger and less educated. Among IUD acceptors, 24% used no modern method at the time of IUD initiation, and 28% reported injectable use in the three previous months. CONCLUSIONS: Convenient, quality, affordable services with demand creation can result in significant uptake of LARCs in settings with low use.

Pregnancy outcomes of managed Medicaid members prescribed home administration of 17 α-hydroxyprogesterone caproate.

OBJECTIVE: Examine adherence to treatment guidelines and rates of recurrent spontaneous preterm birth (SPTB) in managed Medicaid patients prescribed 17 α-hydroxyprogesterone caproate (17P). STUDY DESIGN: A retrospective observational study of women receiving 17P between July 2004 and May 2010 through one of Centene's managed Medicaid programs. Included for analysis were singleton pregnancies without cerclage having SPTB history and prescribed 17P by their physician. Compounded 17P was administered through an outpatient program inclusive of patient education, weekly home nurse visits, and 24-7 telephonic nurse access. A health plan-directed pregnancy management program, Start Smart for Your Baby(®), supported the therapy with case management activities. RESULTS: Of the 790 patients studied, 58.6% initiated 17P in the recommended 16- to 20.9-week gestational age window. Elective discontinuation of 17P occurred in 18.6%. Of the 10,583 17P injections administered, 97.5% were administered within the recommended injection interval of 6 to 10 days. Recurrent SPTB occurred in 28.2% of women studied. CONCLUSION: Managed Medicaid patients enrolled in an outpatient 17P administration program supported with maternal case management have high rates of treatment compliance. Their pregnancy outcomes compare favorably to previously published reports that include both Medicaid and commercially insured patients.

Effects of a pregnancy management program on birth outcomes in managed Medicaid.

OBJECTIVE: Examine the effect of a prenatal program on birth outcomes, specifically birth weight, in a managed Medicaid pregnant population, and identify the potential barriers to obtaining the risk screening information required for successful interventions. DESIGN: Retrospective propensity-adjusted cohort comparison. METHODS: Retrospective propensity-adjusted comparison of pregnant women in a managed Medicaid plan enrolled in a prenatal program and pregnant women who were not enrolled. Program enrollment was initiated by receipt of a Notification of Pregnancy (NOP) risk screening assessment. RESULTS: We demonstrate a statistically significant improvement in delivery outcomes in the women who participate in the pregnancy management program (NOP group) compared with those who do not (non-NOP group). The incidence of low-birth-weight infants was lower in the NOP group compared to the non-NOP group. Odds ratio estimates indicate that the NOP participants are likely to have 7.9% lower adverse event frequency for delivery weights <2500 g; 20% lower adverse event frequency for delivery weights <1500 g; and 31.2% lower adverse event frequency for delivery weights <1000 g. All p values are statistically significant. CONCLUSION: Participation in a pregnancy management program improves birth outcomes in women who are at risk of low-birth-weight deliveries. Early identification of pregnant women and their risk factors for the purpose of enrollment in a managed Medicaid prenatal program is an important factor in improving birth outcomes, specifically birth weight. Our results indicate that this is an important area for investment if birth outcomes are to be improved.

Impact of 17P usage on NICU admissions in a managed medicaid population--a five-year review.

OBJECTIVE: To evaluate whether providing 17 alpha-hydroxyprogesterone caproate (17P) to high-risk pregnant women who have a history of preterm delivery in a Medicaid managed care population reduces the rate of recurrent preterm delivery and neonatal intensive care unit (NICU) admissions. STUDY DESIGN: A 2004-2009 longitudinal review of birth outcomes in 193 singleton pregnant women with a history of spontaneous preterm delivery that were treated with 17P versus a control group. METHODOLOGY: Intervention included offering 17P as a benefit to pregnant women who had a history of spontaneous preterm delivery and who were deemed to be appropriate candidates by their doctor. Members for this study were identified by claims review and obstetrical (OB) case managers in the health plans. A process of early identification, using a variety of data sources, was established along with an educational program aimed at physicians, their office staff, and plan members in order to increase 17P utilization in appropriate candidates. RESULTS: Deliveries with a gestational age of less than 35 weeks decreased significantly from 41.67% in the control group to 26.42% in the 17P group when 17P was initiated by 28 weeks of gestation. The NICU admission rate decreased from 45% in the control group to 33.68% in this 17P group, and was nearly significant. CONCLUSION: Offering 17P as a benefit does have a positive effect on reducing the rate of recurrent preterm delivery and rate of NICU admission in a managed Medicaid population. There was no decrease in effectiveness with delay in initiation of 17P as long as it was started by 28 weeks of gestation.