The Effects of Medicaid Reimbursement of Immediate Postpartum Long-Acting Reversible Contraception on Reproductive Health Outcomes

超过一半的重复妊娠的解释间隔较短(从活产到出生之间的18个月≤ 意外和短时间间隔怀孕有 对妇女及其家庭造成严重的不利健康和社会经济后果。眼前的健康 影响包括早产风险增加、低出生体重、先兆子痫、产妇抑郁和 亲密伴侣的暴力行为和较低的母乳喂养率2-5，20长期而言，意外生育是 与更高的贫困率和更不稳定的家庭有关。8年轻、贫穷、黑人和西班牙裔妇女以及 收入或受教育程度较低的女性更有可能经历意外的短期怀孕。 对于这些后果，2030年健康人的目标是将短间隔怀孕减少20%。 立即接受高效节育措施，如长效可逆避孕(LARC) 产后期(IPP；从分娩到出院之间的时间)可以减少意外和短暂的 间歇性怀孕。然而，计划在产后使用LARC方法的妇女中，有40%-75%没有接受这种方法。 广泛采用IPP LARC的主要障碍是无法获得LARC的报销 产后立即提供的装置和插入物。为了解决这一障碍，一些州的医疗补助计划 计划已开始为IPP LARC插入、设备或两者在 人工和送货费用的报销。如果没有这项政策，各州将使用 “捆绑”付款，不允许报销个别程序、药品或设备。现有 医疗补助IPP LARC报销的证据仅限于在单个医院或单个州内进行分析 着眼于政策采用的短期效果(例如，医院实施和LARC采用)或依赖于 假设所有影响妊娠结局的因素都可以用协变量来解释的方法。这 这项研究试图通过检查长期的、人口水平的影响来填补证据中的空白，利用一种准 实验研究设计。首先，我将评估Medicaid IPP LARC报销政策对 产后使用LARC方法的概率和意外怀孕的概率。接下来，我会 评估补偿政策对短间隔妊娠风险的影响。最后，我将估计 医院类型对短间隔妊娠风险的影响程度。三类医院、教学 医院、医疗补助患者比例较高的医院和340B实体可能对 政策的变化是因为这些医院在短时间内为风险较高的女性人群提供服务 怀孕并有支持性结构，以成功实施IPP LARC方案。12，13本提案 与AHRQ的多个研究优先事项保持一致，包括种族/少数民族、低收入、妇女和 获得护理的途径。

More than half of repeat pregnancies with short interpregnancy intervals (≤18 months between live birth and conception of a subsequent pregnancy) are unintended.1 Unintended and short interval pregnancy has significant adverse health and socioeconomic outcomes for women and their families. The immediate health impacts include increased risk of preterm birth, low birth weight, preeclampsia, maternal depression and intimate partner violence, and lower rates of breastfeeding.2-5,20 In the longer-term, unintended childbearing is associated with higher rates of poverty and less family stability.8 Young, poor, black and Hispanic women, and women of lower income or education are more likely to experience unintended short interval pregnancy.6,7 Due to these consequences, a 2030 Healthy People objective is to reduce short interval pregnancies by 20%.9 Receipt of highly effective birth control like long-acting reversible contraception (LARC) in the immediate postpartum period (IPP; time between delivery and hospital discharge) can reduce unintended and short interval pregnancy. Yet, 40-75% of women who plan to use a LARC method postpartum do not receive it.10 A primary barrier to widespread adoption of IPP LARC has been the inability to obtain reimbursement for LARC devices and insertion provided immediately postpartum. To address this barrier, some state Medicaid programs have started to reimburse for IPP LARC insertion, for the device, or both outside of the reimbursement of labor and delivery costs. Absent this policy, states pay for labor and delivery services using a “bundled” payment that does not allow for reimbursement of individual procedures, drugs, or devices. Existing evidence for Medicaid IPP LARC reimbursement is limited to analyses within single hospitals or single states looking at short-term effects of policy adoption (e.g., hospital implementation and LARC uptake) or rely on methods that assume that all factors affecting pregnancy outcomes can be accounted for with covariates. This study seeks to fill gaps in the evidence by examining long-term, population-level effects utilizing a quasi- experimental research design. First, I will estimate the effect of Medicaid IPP LARC reimbursement policy on the probability of using a LARC method postpartum and probability of an unintended pregnancy. Next, I will estimate the effect of the reimbursement policy on the risk of short interval pregnancy. Lastly, I will estimate the extent to which hospital type impacts the risk of short interval pregnancy. Three types of hospitals, teaching hospitals, hospitals with a high proportion of Medicaid patients, and 340B entities, may be more responsive to the policy change because these hospitals serve populations of women at increased risk for short interval pregnancy and have supportive structures to successfully implement a IPP LARC program.12,13 This proposal is aligned with multiple AHRQ research priorities, including racial/ethnic minorities, low-income, women, and access to care.