Balancing enhanced contraceptive access with risk of reproductive injustice: A United States comparative case study.

OBJECTIVE: We aimed to examine how peripartum contraceptive care quality improvement efforts address or perpetuate reproductive health injustices. STUDY DESIGN: We conducted a comparative case study of inpatient postpartum contraceptive care implementation in 2017 to 2018, using key informant interviews at 11 United States hospitals. After our primary analysis revealed tensions between enhancing access to contraceptive care and patient-centeredness, we conducted the current inductive content analysis guided by 4 questions developed post-hoc: (1) What are healthcare workers' aspirations for contraceptive quality improvement programs? (2) What are healthcare workers' biases regarding peripartum contraceptive care delivery? (3) Do care delivery processes center patients' needs? (4) Do healthcare workers recognize and engage with structural inequities? RESULTS: Seventy-eight key informants (i.e., clinicians, operations staff, administrators) participated. In nine study sites, we observed evidence of interviewees both mitigating and perpetuating reproductive injustice. Many aspired to provide compassionate, patient-centered care, avoid paternalism, and foster patient autonomy. Simultaneously, interviewees demonstrated biases, including implicit subscription to an ideology of stratified reproduction, stereotyping, and "othering." Even when interviewees endorsed goals of patient-centeredness, care delivery processes sometimes prioritized healthcare systems' needs, and patients were not included on quality improvement teams. Many interviewees recognized structural inequities as driving health outcome disparities, yet relied on individual-level solutions like long-acting reversible contraception, and not structural-level interventions, to address them. CONCLUSION: Alongside enthusiasm for delivering compassionate care exist biases, missed opportunities to center patients, and lack of curiosity about the appropriateness of solving structural-level problems with individual-level solutions. IMPLICATIONS: Our findings call for individual and institutional self-reflection, partnership with patients and communities, and other intentional efforts to mitigate potential for harm in initiatives enhancing access to contraceptive care.

Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services.

BACKGROUND: National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits-packages of resources and strategies to facilitate the implementation of new services-are a promising approach for guiding clinical practice change. OBJECTIVE: This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing. STUDY DESIGN: We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]). RESULTS: In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were "extremely" or "somewhat" satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%-79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%-29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%-63%; hospitalization, 45%-58%; outpatient after delivery, 69%-65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care. CONCLUSION: A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.

Implementing immediate postpartum contraception: a comparative case study at 11 hospitals.

BACKGROUND: Immediate postpartum long-acting reversible contraception (LARC) is an evidence-based practice, but hospitals face significant barriers to its adoption. Our objective was to examine how organizational context (e.g., size, employee attitudes toward the clinical practice) and implementation strategies (i.e., the actions taken to routinize a clinical practice) drive successful implementation of immediate postpartum LARC services, with a goal of informing the design of future implementation interventions. METHODS: We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 US maternity hospitals. In 2017-2018, we conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research. Qualitative measures of implementation success included stakeholder satisfaction, routinization, and sustainability of immediate postpartum LARC services. Qualitative content analysis and cross-case synthesis explored relationships among organizational context, implementation strategies, and implementation success. RESULTS: We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. Successful implementation required three essential conditions: effective implementation champions, an enabling financial environment, and hospital administrator engagement. Six other contextual conditions were influential: trust and effective communication, alignment with stakeholders' professional values, perception of meeting patients' needs, robust learning climate, compatibility with workflow, and positive attitudes and adequate knowledge about the clinical practice. On average, sites used 18 (range 11-22) strategies. Strategies to optimize the financial environment and train clinicians and staff were commonly used. Strategies to plan and evaluate implementation and to engage patients emerged as promising to address barriers to practice change, yet were often underused. CONCLUSIONS: Implementation efforts in maternity settings may be more successful if they select strategies to optimize local conditions for success. Our findings elucidate key contextual conditions to target and provide a menu of promising implementation strategies for incorporating recommended contraceptive services into routine maternity practice. Additional prospective research should evaluate whether these strategies effectively optimize local conditions for successful implementation in a variety of settings.

Breakdown in the expedited partner therapy treatment cascade: from reproductive healthcare provider to the pharmacist.

BACKGROUND: The rising incidence rates of sexually transmitted infections in the United States highlight the need for concurrent treatment of patients and their sexual partners. Expedited partner therapy allows healthcare providers to offer antibiotic prescriptions or medications to an index patient for distribution to their sexual partner(s) without evaluating the partner. We hypothesized that there was a gap between expedited partner therapy policy at the state level and its downstream implementation by community pharmacists. OBJECTIVE: The objectives of our study were to evaluate pharmacists' expedited partner therapy knowledge and practices in 41 expedited partner therapy-permissible US states, to determine whether there were differences in practice based on the length of time expedited partner therapy was permissible in the state and chlamydia incidence rates, and to measure the cost of expedited partner therapy treatment. STUDY DESIGN: A randomized cohort of pharmacists (n=335) was invited to complete a telephone interview from November 2017 through January 2018. Descriptive statistics were calculated and stratified by early, mid, and late expedited partner therapy-adopter status based on the year of the state's expedited partner therapy enactment and the state's chlamydia incidence rate. Fisher's exact test and 1-way analyses of variance were used to compare measures across strata. RESULTS: We had 143 pharmacists (42.7%) agree to complete the survey. Among our respondents, 40.6% (n=58/143) indicated that they were aware of expedited partner therapy; 14.7% (n=21/143) reported that they had ever received an expedited partner therapy prescription, and 97% (n=139/143) reported that they would dispense an expedited partner therapy prescription if they received 1 in the future. These findings were stable across the 6 strata defined by early, mid, or late expedited partner therapy-adopter and high or low incidence rates of chlamydia status. Mean cost of azithromycin 1000 mg and cefixime 400 mg for treatment of chlamydia and gonorrhea was $22.17 (95% confidence interval, 20.29-24.05) and $30.46 (95% confidence interval, 28.65-32.26), respectively. CONCLUSION: Fewer than one-half of the pharmacists were aware of expedited partner therapy. A small minority of pharmacists reported ever having received an expedited partner therapy prescription, regardless of the length of time expedited partner therapy had been legal in their states and the incidence of chlamydia. However, almost all pharmacists reported that they would dispense an expedited partner therapy prescription if they received 1. Additionally, costs were high for expedited partner therapy for self-pay patients. These data suggest that there are opportunities to increase expedited partner therapy utilization by healthcare providers, patients, and pharmacists.