Influence of Access to Immediate Postpartum LARCs on Interpregnancy Interval [16J

Abstract

INTRODUCTION: Assess the effect of immediate access to postpartum (PP) LARCs (long-acting reversible contraceptives) and contraceptive access through Medicaid expansion (ME) on short interpregnancy interval (IPI) rates in the US. METHODS: Population-based retrospective cohort study of all US live births, 2016 (n=3,956,112), using Birth Certificate data. We categorized states into those that adopted Medicaid expansion (+ME), which improves access to PP contraception, and states that provide access to immediate PP-LARCs (https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/Immediate-Postpartum-LARC-Medicaid-Reimbursement). States were classified as: (1) +ME/+LARC, (2) +ME/-LARC, (3) –ME/+LARC, (4) –ME/-LARC. Births from 13 states who adopted ME after 1/1/2014 were not included. Multivariate logistic regression estimated the relative influence of ME and PP-LARCs on the outcome of short IPI (<12 months), after adjusting for maternal race, age, marital status, and WIC. RESULTS: The study population comprised 1,831,665 births to multiparous women with data on IPI among included states. Of those, 50% were in 19 states with +ME/+LARC, 151,999 (8%) in 5 states with +ME/-LARC, 742,836 (40%) in 12 states with –ME/+LARC, and 3,876 (0.2%) in one state with –ME/-LARC. The rate/risk of short IPI was lowest in states with ME plus immediate PP-LARC access (16.17%, 95% CI 16.09-16.25%), adjusted RR 0.926, 95% CI 0.92-0.93). Short IPI rates and adjusted risks were slightly higher in states that adopted only one program or neither: +ME/-LARC 18.05% (CI 17.86-18.25%), -ME/+LARC 18.12% (CI 18.03-18.20%), -ME/-LARC 18.83% (CI 17.60-20.06%), with highest risk in the state with –ME/-LARC, adjRR 1.12, CI 1.05-1.19. CONCLUSION: These data demonstrate that both Medicaid expansion and access to immediate PP LARCs decrease the frequency of short IPI, which may reduce adverse birth outcomes in the US associated with insufficient birth spacing.