title: Six- and twelve-month documented removal rates among women electing postpartum inpatient compared to delayed or interval contraceptive implant insertions after Medicaid payment reform.
abstract: This study aims to document 6- and 12-month removal rates for women receiving the contraceptive implant inpatient postpartum versus those receiving the same contraceptive method during an outpatient visit, in a setting where postpartum inpatient long-acting reversible contraceptive (LARC) services (devices plus provider insertion costs) are reimbursed by Medicaid.
  
  
  
  We conducted a retrospective cohort study among Medicaid-enrolled women using medical record review for all women receiving the etonogestrel implant between July 1, 2007 and June 30, 2014. We compared the percentage of women with the implant removed at 6 and 12 months as well as reasons for early removal, for inpatient postpartum implant insertions vs. delayed postpartum or interval outpatient implant insertions.
  
  
  
  A total of 4% of women (34/776 insertions) had documented implant removal within 6 months post-insertion, with no difference between postpartum inpatient and outpatient (delayed postpartum or interval). A total of 12% (62/518 insertions) of women had documented implant removal within 12 months. A lower percentage of women with postpartum inpatient insertions had the implant removed at 12 months post-insertion, compared to outpatient insertions (7% vs. 14%, p=.04). After controlling for age, parity, race and body mass index, women with postpartum inpatient insertions were less likely to have the implant removed within 12 months (OR=0.44, 95% CI 0.20-0.97). The most commonly stated reason for removal was abnormal uterine bleeding, regardless of insertion timing.
  
  
  
  In a setting with a Medicaid policy that covers postpartum inpatient LARC insertion, a low percentage of women who received an implant immediately postpartum had it removed within 1 year of insertion.
  
  
  
  A Medicaid payment policy that removes institutional barriers to offering postpartum inpatient contraceptive implants to women free-of-charge may facilitate meeting women's desires and intentions to delay subsequent pregnancy, as evidenced by low removal rates up to 12 months post-insertion. Further research with women is needed to assess how these services meet their postpartum contraceptive needs and desires to postpone or prevent subsequent pregnancy.
authors.affiliation: Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Road, Greenville, SC 29605, USA. Electronic address: acrockett@ghs.org.
authors.forename: Amy H
authors.initials: AH
authors.lastname: Crockett
authors.affiliation: Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Road, Greenville, SC 29605, USA. Electronic address: lbundon@ghs.org.
authors.forename: Lesley Bundon
authors.initials: LB
authors.lastname: Pickell
authors.affiliation: Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Road, Greenville, SC 29605, USA. Electronic address: heberleine@gmail.com.
authors.forename: Emily C
authors.initials: EC
authors.lastname: Heberlein
authors.affiliation: Choose Well Initiative, 1501 Main Street, Suite 150, Columbia, SC 29201, USA; Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, 921 Assembly Street, Columbia, SC 29208, USA. Electronic address: dbillings@newmorningfoundation.org.
authors.forename: Deborah L
authors.initials: DL
authors.lastname: Billings
authors.affiliation: Department of Obstetrics and Gynecology, Greenville Health System, 890 W. Faris Road, Greenville, SC 29605, USA. Electronic address: bmills@ghs.org.
authors.forename: Benjie
authors.initials: B
authors.lastname: Mills
mesh_terms: D000293:Adolescent; D000328:Adult; D003271:Contraceptive Agents, Female / Q000008:administration & dosage; D017046:Cost Savings; D017135:Desogestrel / Q000008:administration & dosage; D020878:Device Removal / Q000706:statistics & numerical data*; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D007297:Inpatients; D007434:Intrauterine Devices / Q000191:economics*; D016015:Logistic Models; D008484:Medicaid; D010045:Outpatients; D010549:Personal Satisfaction; D049590:Postpartum Period; D012189:Retrospective Studies; D013022:South Carolina; D013997:Time Factors; D014481:United States; D055815:Young Adult
chemical_list: D003271:Contraceptive Agents, Female; C044815:etonogestrel; D017135:Desogestrel
keywords: Contraceptive implant; Medicaid; Nexplanon; Postpartum contraception