Statewide quality improvement initiative to implement immediate postpartum long-acting reversible contraception

BACKGROUND: Women face barriers to obtaining contraception and
postpartum care. In a review of Tennessee birth data from 2014, 56% of
pregnancies were unintended, 22.7% were short-interval pregnancies,
and 57.9% of women who were not intending to get pregnant were not
using contraception. Offering long-acting reversible contraceptive
methods in the immediate postpartum period allows women who desire
these effective methods of contraception to obtain unobstructed access
and lower unintended and short-interval pregnancy rates.
OBJECTIVE: We report the experience of Tennessee’s perinatal quality
collaborative that aimed to address unintended and short-interval pregnancy by increasing access to immediate postpartum long-acting
reversible contraception through woman-centered counseling and
ensuring reimbursement for devices. This followed a policy change in
November 2017 that allowed women who were insured under Tennessee
Medicaid programs (TennCare) to achieve access to immediate postpartum long-acting reversible contraception.
STUDY DESIGN: From March 2018 to March 2019, 6 hospital sites
participated in this statewide quality improvement project that was based
on the Institute of Health Improvement Breakout Collaborative model. An
evidence-based toolkit was created to provide guidance to the sites.
During the year of implementation, monthly huddles occurred, and each
facility took a differing amount of time to implement immediate
postpartum long-acting reversible contraception. Various statewide and
hospital-specific barriers occurred and were overcome throughout
the year.
RESULTS: In total, 2012 long-acting reversible contraception devices
were provided to eligible and desiring women. All but 1 institution was able
to offer immediate postpartum long-acting reversible contraception by
March 2019. Reimbursement was the biggest statewide barrier because
rates were low initially but improved through intensive intervention by
dedicated team members at each site and the state level. Even with
dedicated team members, false assurances were given repeatedly by
billing and claims staff.
CONCLUSION: A statewide quality improvement project can increase access to immediate postpartum long-acting reversible
contraception. Implementation and reimbursement require a dedicated
team and coordination with all stakeholders. Verification of reimbursement with leaders at TennCare was essential for project sustainment and facilitated improved reimbursement rates. The impact on
unintended and