Postpartum Visit and Contraception Study Arden Handler, DrPH, Rachel Caskey, MD, Kristin Rankin, PhD, Sadia Haider, MD, MPH University of Illinois School of Public Health Prepared for the Illinois Department of Healthcare and Family Services Project Dates: May 16th, 2014 to January 31st, 2015 Project Director: Katrina Stumbras, MPH Research Assistants: Vida Henderson, PharmD, MPH, Molly Murphy, MPH, Elizabeth Berkeley, Micaella Verro, Amy Solsman A special thank you to Tierra Williams, Sonya Dhanvanthari, and April Parks for their assistance with this project. This document was developed under grant CFDA 93.767 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. However these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the Federal Government. Postpartum Visit and Contraception Executive Summary Background Researchers at the University of Illinois School of Public Health undertook a multi-part effort to: identify and summarize the research related to what is known about the postpartum visit, strategies for increasing its use, as well as strategies for increasing uptake of postpartum contraception; to determine women’s and providers’ perspectives on alternative approaches to the delivery of postpartum care and contraception; and, to specifically explore the role of the Well-Baby Visit (WBV) in the early postpartum period as a time for women to discuss reproductive life planning and family planning needs. This work was funded by the Illinois Department of Healthcare and Family Services through its CHIPRA initiative. Why is this research important? Unintended pregnancy is highly prevalent in the US and is associated with increased risk of adverse reproductive and perinatal outcomes. Postpartum women are at particularly high risk of unintended pregnancy with 10 – 44% of women having an unintended pregnancy in the first postpartum year (Chen et al., 2010). While some women receive contraception in the hospital after delivery, actual provision varies and most often women do not receive contraception until the six-week postpartum visit. However, in the few studies that document women’s use of the postpartum visit, estimates for non- attendance at the visit vary (11%-40%) (Bryant et al., 2006; Lu & Prentice, 2002; Chu et al., 2004; Kabakian-Khasholian & Campbell, 2005; Weir et al., 2011; IDHFS, 2014). Examining ways to increase utilization of the postpartum visit and/or increase access to postpartum care in alternative settings is essential. Providing postpartum women with access to effective methods of contraception and care is clearly the most straightforward approach to reducing unintended pregnancy in this group. As policy- makers discuss new approaches to the delivery of postpartum care, additional information is needed on women’s perceptions of barriers to and preferences for the timing and location of the postpartum visit, and likewise, barriers to and preferences for accessing postpartum contraception. Information is also needed about providers’ attitudes and comfort with new approaches to increasing the utilization of postpartum contraception. This includes the potential for adopting more focused interventions in the perinatal period and consideration of alternative approaches for the delivery of contraception in the postpartum period such as the provision of contraceptive counseling and/or services at the Well-Baby Visit. Additionally, approaches which focus on making reproductive counseling routine in all aspects of women’s health care such as utilization of the CDC’s Reproductive Life Plan Tool (RLPT) for Health Professionals are gaining momentum. As such, an examination of the acceptability and feasibility of implementing such approaches and tools in multiple settings is needed. What were the goals of this research and how were they addressed? Research Objective Action To document what is known to date about women’s Review of the current literature and electronically published preferences and experiences with respect to utilization of material related to postpartum care and contraception counseling care and contraception in the postpartum period. was completed. To determine the perceptions of postpartum women of diverse racial and ethnic backgrounds with respect to Twenty in-depth interviews were completed with postpartum barriers to and preferences for the timing and location of the women. postpartum visit and the receipt of postpartum contraception. To determine providers’ (OB-GYN, FP, and CNM) current practices during prenatal and/or postpartum care used to Twelve in-depth phone interviews were completed with assist women to plan and space their pregnancies as well as providers who have regular contact with postpartum women. their willingness to introduce alternative approaches into their practice. Over 25 UIC pediatric residents were trained to use an adapted To assess the feasibility and acceptability of introducing an RLPT with the mother of any infant 16 weeks or less during the adaptation of the CDC’s Reproductive Life Plan Tool at the child’s visit with the pediatrician, followed by completion of a Well-Baby Visit. focus group and survey with pediatricians. Postpartum Visit and Contraception Executive Summary What do the research findings mean for postpartum care moving forward? Findings from the literature reviews and key-informant interviews with postpartum women indicate that although women view the postpartum period as an important time to be receiving support from the health care system, there are a number of barriers and issues preventing them from obtaining these services. All sources from this research (i.e., literature, women interviews, and provider interviews) emphasize the unique needs of each postpartum woman and the importance of establishing multiple mechanisms for ensuring they are receiving their desired postpartum care and contraception including being able to obtain contraception before being discharged from the delivery hospital. Although there were a number of interventions with positive findings related to increasing uptake of care and contraception in the postpartum period, not enough research has been completed to conclusively support any one approach. Conversely, this supports the overarching theme derived from this research: Women require flexibility and multiple options for receiving care and contraception in the postpartum period. A novel way to increase access to contraception in the postpartum period is to capitalize on the multiple interactions most postpartum women have with their infant’s pediatrician at the Well-baby Visit. After discussion with women and providers in the key informant interviews as well as with pediatricians after implementing an intervention using this model, it appears as though the Well-Baby Visit for young infants has the potential to be a meaningful and feasible method of reaching postpartum women. While the limitations and concerns from pediatricians and postpartum women, in particular with regard to detracting attention from the infant, may prevent this intervention from appealing to all women and providers, further exploration is warranted to establish ways to address these concerns and increase postpartum women’s access to care. With the recognition that there is no evidence-based ‘gold-standard’ with regard to care and contraceptive counseling in the postpartum period, it is essential that policies and funding support increased access to postpartum care at all available intersections with the health care system as well as promote innovative approaches to reaching the postpartum population. Recommendations . Policies and funding (Medicaid reimbursement) should support increased flexibility with regard to the location, timing, and frequency of the postpartum visit. In particular, reimbursement by IDHFS for at least two postpartum visits within the first 8 weeks postpartum appears warranted. Interventions and initiatives to increase attendance at the postpartum visit should target factors that are amenable to intervention. One such factor is prior health care utilization including care during the prenatal period. Reinvesting in initiatives to increase access to and utilization of prenatal care among women on Medicaid may be a key strategy to increasing postpartum visit utilization. IDHFS policies and funding should support increased flexibility with regard to the location, timing, and frequency of contraceptive counseling and delivery in the postpartum period, including the provision of contraception such as LARC methods at delivery or before the woman leaves the delivery hospital. Similar to perinatal depression screening, IDHFS should consider reimbursement for contraceptive counseling and reproductive life planning discussions at the Well-Baby Visit. This will require education of pediatric providers about the use of either one specific Reproductive Life Plan tool or a menu of Reproductive Life Plan tools (e.g., CDC RLPT, Oregon One Key Question, modified tools, etc.). Postpartum Visit and Contraception Integrated Summary of Findings Integrated Summary of Findings Background In Spring 2014 – December 2015, researchers at the University of Illinois School of Public Health undertook a multi-part effort to: identify and summarize the research literature related to what is known about the postpartum visit, strategies for increasing its use, as well as strategies for increasing uptake of postpartum contraception;