Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program

Original Research ajog.org

GYNECOLOGY

Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program

Heike Thiel de Bocanegra, PhD; Monica Braughton, MPH; Mary Bradsberry; Mike Howell, MA; Julia Logan, MD; Eleanor Bimla Schwarz, MD 

BACKGROUND: Considerable racial and ethnic disparities have been [aOR], 0.73; 95% confidence interval [CI], 0.71�0.76), were less likely to

identified in maternal and infant health in the United States, and access to 

postpartum care likely contributes to these disparities. Contraception is an

important component of postpartum care that helps women and their

families achieve optimal interpregnancy intervals and avoid rapid repeat

pregnancies and preterm births. National quality measurements to assess

postpartum contraception are being developed and piloted.

OBJECTIVE: To assess racial/ethnic variation in receipt of postpartum care and contraception among low-income women in California.

STUDYDESIGN:We conducted a prospective cohort study of 199,860 Californian women aged 15�44 with a Medicaid-funded delivery in 2012. We examined racial/ethnic variation of postpartum care and contraception

using multivariable logistic regression to control for maternal age, lan-

guage, cesarean delivery, Medicaid program, and residence in a primary

care shortage area (PCSA).

RESULTS: Only one-half of mothers attended a postpartum visit (49.4%) or received contraception (47.5%). Compared with white women,

black women attended postpartum visits less often (adjusted odds ratio

Cite this article as: Thiel de Bocanegra H, Braughton M, Bradsberry M, et al. Racial and ethnic disparities

in postpartum care and contraception in California’s

Medicaid program. Am J Obstet Gynecol

2017;217:47.e1-7.

0002-9378/$36.00 ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2017.02.040

receive any contraception (aOR, 0.83; 95% CI, 0.78�0.89) and were less likely to receive highly effective contraception (aOR, 0.64; 95% CI,

0.58�0.71). Women with Spanish as their primary language were more likely to get any contraception (aOR, 1.15; 95% CI, 1.11�1.19) but had significantly lower odds of receiving a highly effective method (aOR, 0.94;

95% CI, 0.90�0.99) compared with women with English as their primary language. Similarly, women in PCSAs had a greater odds of getting any

contraception (aOR, 1.06; 95% CI, 1.03�1.09), but 24% lower odds of getting highly effective contraception than women not living in PCSAs

(aOR, 0.76; 95% CI, 0.73�0.79). CONCLUSION: Significant racial/ethnic disparities exist among low- income Californian mothers’ likelihood of attending postpartum visits

and receiving postpartum contraception as well as receiving highly

effective contraception.

Key words: health disparities, highly effective contraception, Medicaid, postpartum care, postpartum contraception

onsiderable racial and ethnic dis-

C parities have been identified in maternal and infant health in the United States.1 In particular, black women in the United States are at greater risk of poor infant and maternal health outcomes2,3 

and face high rates of rapid repeat pregnancies and preterm births.4e7 The reasons for this variation, however, are not understood fully. Although biolog- ical mechanisms may underlie some of these differences, access to preconcep- tion, prenatal, and postpartum care also likely contribute to these disparities.8

Contraception is an important compo- nent of postpartum care that helps women and their families achieve

optimal interpregnancy intervals and avoid rapid repeat pregnancies and preterm births.9e11 Because highly effective forms of contraception (such as intrauterine devices and implants) are associated with optimal interpreg- nancy intervals, access to these forms of contraception is particularly important.10,12,13

In 2012, California was one of 26 states that received federal funding to collect, report, and analyze data on the Core Set of Health Care Quality Mea- sures for Adults Enrolled in Medicaid (Adult Core Set). The Adult Core Set included the Healthcare Effectiveness Data and Information Set (HEDIS) Postpartum Care Rate measure,14 which examines postpartum visits between 21 and 56 days after delivery. These visits commonly address breastfeeding, contraception, postpartum depression, and medical conditions such as diabetes and hypertension. In California, publicly funded family

planning services are offered through Medi-Cal, California’s Medicaid

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program, and California’s Family Plan- ning, Access, Care, and Treatment (Family PACT) program. Women whose deliveries are covered by Medi-Cal are eligible for postpartum care and contraception for at least 60 days post- partum. If they are ineligible for full- scope Medi-Cal beyond this period, they can receive family planning services through Family PACT. Medi-Cal post- partum visit rates in California, espe- cially among black women, have been below national averages; thus, increasing these rates became a focus of California’s Medi-Cal quality strategy.15 California’s Department of Health Care Services also participated in the Centers for Medicare & Medicaid Services Postpartum Learning Series, which focused on improving postpartum care, including postpartum contraception.16

In this analysis, we examined differ- ences in postpartum visit rates and receipt of postpartum contraception among women receiving publicly fun- ded health care in California by race/ ethnicity, language preference, and

rican Journal of Obstetrics & Gynecology 47.e1

 

 

Original Research GYNECOLOGY ajog.org

residence in a primary care shortage area (PCSA).

Materials and Methods HEDIS technical specifications were applied to Medi-Cal administrative data (including claims and encounter data) to identify a cohort of women eligible for postpartum visits.17 Women with de- liveries of live births between November 6, 2011, and November 5, 2012, were eligible. Deliveries of live births were identified with Current Procedural Ter- minology codes, International Classifi- cation of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis, and ICD-9-CM procedure codes indic- ative of live birth. Delivery dates were defined by service dates on claims most likely to be billed at the time of delivery; delivery dates from encounter data were verified against delivery payment re- cords. Women were included once for every live birth delivery in this period. Fewer than 100 women had a second birth during the 12-month period.

Using this methodology, we identified 245,623 deliveries to women ages 15�44 years. Because Medi-Cal and Family PACThave separate enrollment systems, a probabilistic linking algorithm was used to link these Medi-Cal clients to their Family PACT Health Access Program identification numbers and associated claims. The linking algorithm is based on the Fellegi-Sunter model of record link- age18 that mathematically decides whether a pair of records from two disparate data files belongs to the same entity (person). Consistent with the HEDIS requirements for continuous enrollment in Medicaid, women who were not enrolled continuously in Medi- Cal or Family PACT from 43 days prior to 99 days after delivery were excluded (N ¼ 32,650). Women with incomplete claims data or missing data on available covariates of interest (race/ethnicity, age, language, residence, and delivery type) (N ¼ 13,113) also were excluded. Multi- variable logistic regression was used to examine the odds of postpartum care for the remaining subpopulation (N ¼ 199,860). Finally, we conducted multi- variable logistic regression to assess the odds of receiving any contraception and

47.e2 American Journal of Obstetrics & Gynecolo

highly effective contraception among women who returned for a HEDIS post- partum visit without previous receipt of contraception (N ¼ 87,304). Per HEDIS guidelines, Current Pro-

cedural Terminology codes, ICD-9-CM diagnosis or procedure, uniform billing revenue, and Healthcare Common Pro- cedure Coding System codes were used to identify postpartum care 21�56 days after delivery.14 These codes address procedures and diagnoses that include provision of postpartum care, pelvic examinations, cervical cytology, intra- uterine contraceptive (IUC) insertion/ removal, or diaphragm fitting. One Healthcare Common Procedure Coding System code for postpartum care (Z1038) that was used in California in 2012 also was included. Women identified as having received

postpartum contraception included those with at least one paid Medi-Cal claim, Family PACT claim, or Medi-Cal Managed Care encounter record for contraception between 0 and 99 days postpartum (3 months after delivery plus a 2-week buffer for scheduling the visit) for contraception. Women with no paid claims for contraceptives in Medi- Cal or Family PACTwere categorized as having no contraceptive method. Women with multiple forms of contra- ception were categorized by the most effective method received. Contracep- tives were categorized as highly effective (IUC, implants, or female sterilization), moderately effective (injectable, pills, patch, ring, or diaphragm), or less effective (condoms, spermicide, or sponge).19

Medi-Cal and Family PACT enroll- ment records were used to identify race/ ethnicity (white, black, Latina, Asian/ Pacific Islander, or other/unknown), primary language (English, Spanish, or other), and maternal age at delivery. Because residence in a rural community or a community with a limited number of clinicians can make it difficult to receive medical services in a timely manner, we also adjusted for residence in a PCSA. This was defined as having resided in a census tract designated by the California Healthcare Workforce Policy Commission as a PCSA for at least 1

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month between 0 and 99 days post- partum. One month was chosen because it was the shortest period of time avail- able in the dataset to measure access to primary care.20

Deliveries that had claims with pro- cedure or diagnosis codes for cesarean delivery within 7 days of their delivery date were considered cesarean. Deliveries with at least one vaginal delivery pro- cedure ordiagnosis codewere considered vaginal. If no codes indicated mode of delivery, the delivery typewas considered missing. Women were assigned to the publicly funded health care program (Medi-Cal Fee for Service, Medi-Cal Managed Care health plans, or Family PACT), where they were enrolled on the 99th day postpartum.

Rates of HEDIS postpartum visits, receipt of any contraception, and receipt of highly effective contraception were examined by maternal demographics. Associations between these covariates and the 3 postpartum outcomes of in- terest (ie, any postpartum visit, receipt of any postpartum contraception, receipt of highly effective postpartum contracep- tion) were assessed via Pearson c2 tests. Finally, we conducted multivariable logistic regression to assess the adjusted odds of receiving any contraception and highly effective contraception among the 87,304 women who had not received contraception prior to their postpartum visit.

All analyses were conducted with SAS 9.2 (Cary, NC). This study was approved by the Committee of Human Subjects Research of the University of California, San Francisco, and the California Health and Human Services Agency’s Commit- tee for the Protection of Human Subjects.

Results Postpartum visit rates Of 199,860 women with deliveries, the majority were Latina (67.4%). One-half (49.9%) spoke English, and 46% spoke Spanish as their primary language. More than one-half (57.9%) were 20�29 years of age at delivery, 33.9% had cesarean deliveries, and 64.7% resided in a PCSA during their postpartum period. Roughly one-half (49.0%) were enrolled

 

 

TABLE 1 Demographic and service delivery characteristics of low-income women ages 15-44 years delivering in California, 2012

Maternal demographics Total population, n (%)

Women without contraception before first postpartum visit, n (%)

Overall 199,860 (100%) 87,304 (100%)

Race/ethnicity

White 31,371 (15.7%) 12,338 (14.1%)

Black 16,352 (8.2%) 4791 (5.5%)

Latina 134,607 (67.4%) 62,713 (71.8%)

Asian/Pacific Islander 12,512 (6.3%) 5323 (6.1%)

Other 5018 (2.5%) 2139 (2.5%)

Primary language

English 99,716 (49.9%) 37,254 (42.7%)

Spanish 92,721 (46.4%) 46,853 (53.7%)

Other 7423 (3.7%) 3197 (3.7%)

Age at delivery, y

15�19 23,485 (11.8%) 9651 (11.1%) 20�29 115,767 (57.9%) 51,451 (58.9%) 30�39 55,664 (27.9%) 24,160 (27.7%) 40�44 4944 (2.5%) 2042 (2.3%)

Resided in PCSA

Yes 129,303 (64.7%) 55,133 (63.2%)

No 70,557 (35.3%) 32,171 (36.9%)

Cesarean delivery 67,781 (33.9%) 26,045 (29.8%)

Attended postpartum visit 21�56 d after delivery (as defined by HEDIS)

98,719 (49.4%) 87,304 (100.0%)

Received any contraception 0�99 d postpartum

94,922 (47.5%) 45,924 (52.6%)

Received highly effective contraception 0�99 d postpartum

32,794 (16.4%) 13,784 (15.8%)

HEDIS, Healthcare Effectiveness Data and Information Set; PCSA, primary care shortage area.

Thiel de Bocanegra et al. Disparities in postpartum contraception. Am J Obstet Gynecol 2017.

ajog.org GYNECOLOGY Original Research

in Medi-Cal Managed Care, 43.3% were enrolled inMedi-Cal Fee for Service, and 7.7% were enrolled in Family PACT on the 99th day postpartum. Among these 199,860 women, 49.4% had a HEDIS postpartum visit (Table 1).

In multivariable logistic regression analysis, black women had 27% lower odds of attending an HEDIS postpartum visit than white women (adjusted odds ratio [aOR], 0.73; confidence interval [CI], 0.71 to 0.76).Women younger than the age of 20 had lower odds of attending a HEDIS postpartum visit than women

ages 20�29 (aOR, 0.82; CI, 0.80� 0.85). Women residing in PCSAs also were less likely to make postpartum visits (aOR, 0.88; CI, 0.86�0.89). Finally, women who had a cesarean delivery also had lower odds of returning for a HEDIS postpartum visit (aOR, 0.81; CI, 0.80 to 0.83) (Table 2). In contrast, women who spoke primarily Spanish (aOR, 1.65; CI, 1.61 to 1.69) and women who were enrolled in Family PACTat the end of the postpartum period (aOR, 1.19; CI, 1.15 to 1.24) had greater odds of returning for a HEDIS postpartum visit compared

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with their peers, when we controlled for all covariates (Table 2).

Receipt of contraception Among the 49.4%ofwomenwho received postpartum care, 11,432 already had received contraception before their first postpartum visit. Among the remaining 87,304 women who returned for a visit with no previous postpartum contracep- tion, 52.6% received contraception before 99 days postpartum. Compared with the full population, women coming to their HEDIS postpartum visit without a con- traceptive method were more likely to be Latina (71.8% vs 67.4%), Spanish speaking (53.7% vs 46.4%), and returning after a vaginal delivery (70.2% vs 66.1%) (Table 1).

In multivariable logistic regression controlled for all covariates in this same subpopulation (n ¼ 87,304), Latina women were more likely to have received any contraception than white women (aOR, 1.13; CI, 1.08 to 1.19), whereas black, Asian, and other groups had significantly lower odds of receiving post- partum contraception than white women (Table 3). Women had greater odds of receiving any postpartum contraception if they primarily spoke Spanish (aOR, 1.15; CI, 1.11 to 1.19). Women with cesarean deliveries had lower odds of receiving postpartum contraception compared with womenwith vaginal deliveries (aOR, 0.84; CI, 0.81 to 0.86). Lastly, the odds of receiving postpartum contraception decreased with age. Although adolescents and women ages 20�29 years had similar odds of receiving contraception, women ages 30-39 (aOR, 0.81; CI, 0.78 to 0.83) and40-44 (aOR, 0.63,CI, 0.57 to 0.69) had lower odds of receiving postpartum contraception than women ages 20�29 (Table 3).

Highly effective contraception Sixteen percent of all women received a highly effective postpartum contracep- tive method (sterilization, IUC, or implant). As with the receipt of any postpartum contraception, women older than 30 years of age had lower odds of receiving highly effective contraception. Black and Asian women were less likely to receive highly effective contraception

rican Journal of Obstetrics & Gynecology 47.e3

 

 

TABLE 2 Receipt of any postpartum care among low-income women ages 15L44 years delivering in California, adjusted for select covariates, 2012 (N [ 199,860)

Maternal demographics

Received postpartum care 21�56 d after delivery, %

Adjusteda odds of receiving postpartum care 21�56 d after delivery, aOR (CI)

Race/ethnicity

White 43.4% Referent

Black 33.3% 0.73 (0.71�0.76) Latina 53.0% 1.03 (1.00�1.07) Asian/Pacific Islander 47.7% 1.11 (1.06�1.16) Other 46.6% 1.06 (1.00�1.13)

Primary language

English 41.6% Referent

Spanish 57.9% 1.65 (1.61�1.69) Other 48.1% 1.14 (1.08�1.21)

Age at delivery, y

15�19 44.0% 0.82 (0.80�0.85) 20�29 48.8% Referent 30�39 52.7% 1.09 (1.07�1.12) 40�44 52.8% 1.07 (1.01�1.13)

Ever resided in PCSA

Yes 48.1% 0.88 (0.86�0.89) No 51.8% Referent

Delivery method

Cesarean 46.2% 0.81 (0.80�0.83) Vaginal 51.0% Referent

aOR, adjusted odds ratio; CI, confidence interval; PCSA, primary care shortage area.

a Model adjusted for state-funded health care program (Medi-Cal Fee for Service, managed care, Family PACT) at 99 days.

Thiel de Bocanegra et al. Disparities in postpartum contraception. Am J Obstet Gynecol 2017.

Original Research GYNECOLOGY ajog.org

thanwhite women, even inmultivariable models (Table 3). Although women who spoke primarily Spanish were more likely to receive some form of contra- ception 0�99 days postpartum, they had significantly lower odds of receiving a highly effective reversible method compared with women who spoke pri- marily English (aOR, 0.94; CI, 0.90 to 0.99). Women in primary care shortage areas had marginally greater odds of getting any contraception but had a 24% lower odds of getting a highly effective reversible form of contraception than women not living in primary care shortage areas (aOR, 0.76; CI, 0.73 to 0.79) (Table 3).

47.e4 American Journal of Obstetrics & Gynecolo

Comment This study found significant racial/ethnic disparities in postpartum visit rates and receipt of postpartum contraception among women served by the Medi-Cal program, even after we controlled for maternal age, delivery type, and residence in a primary care shortage area.Only one- half of women with Medi-Cal�funded deliveries had evidence of a postpartum visit, which is below the 2012 national Medicaid HMO average of 63%.21 In particular, blackwomenwere less likely to attend postpartum visits and receive contraception than white and Latina women. These findings are consistent with previous studies.22 Although

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contraceptive preferences vary by in- dividuals, because black women overall are more likely to experience short interpregnancy intervals23 and poor maternal and infant health outcomes, programs such as the Black Infant Health program24 should be strengthened.

Because Latina women on Medi-Cal are more frequently without health in- surance 3 months after delivery,22 they may be more motivated to return for a postpartum visit before losing their limited scope Medi-Cal insurance (about 60 days after delivery). Similarly, women in PCSAs were significantly more likely to get any contraception compared with their peers but signifi- cantly less likely to get a highly effective form of contraception.Women and their clinicians, particularly those in rural areas or with transportation challenges, may be more motivated to take care of contraceptive needs at the visit rather than planning a return appointment. Although this dataset did not include information on provider specialties available in the PCSA, a sizable number of women receive family planning ser- vices from primary care Medi-Cal and Family PACT providers.25 Our findings suggest that geographic access to pro- viders needs to be complemented by clinician training and other inter- ventions to ensure the provision of highly effective contraception.26

A limitation of this analysis is its reli- ance on administrative claims and encounter data, which can undercount contraceptive method provision if cor- rect claims were not submitted, if clients paid for contraceptives themselves, had already picked up prescription contra- ception prior to birth, or if they relied on their partner’s method (vasectomy, condom use). We also do not know how many women in the cohort had experi- enced fertility challenges or how many were in same-sex relationships. The use of administrative data also limited the number of available covariates. Although information on the mother’s parity or country of birth was not avail- able, we were able to control for delivery type (cesarean or vaginal) and residence in a primary care shortage area. Impor- tantly, however, claims data have no

 

 

TABLE 3 Receipt of any postpartum contraception within 99 days, 2012 (N [ 87,304)a

Maternal demographics Received any contraception Adjusted odds (95% CI)

Received highly effective contraception, % Adjusted odds ratio (95% CI)

Race/ethnicity

White 50.4% Referent 18.3% Referent

Black 46.8% 0.83 (0.78�0.89) 12.4% 0.64 (0.58e0.71) Latina 54.7% 1.13 (1.08e1.19) 15.9% 0.95 (0.90e1.00)

Asian/Pacific Islander 41.8% 0.81 (0.76e0.87) 11.7% 0.65 (0.59e0.72)

Other 43.5% 0.80 (0.73e0.88) 15.8% 0.89 (0.78e1.01)

Primary language

English 51.3% Referent 16.8% Referent

Spanish 54.7% 1.15 (1.11e1.19) 15.3% 0.94 (0.90e0.99)

Other 36.9% 0.68 (0.62e0.74) 11.2% 0.76 (0.67e0.86)

Age at delivery, y

15�19 56.4% 1.02 (0.98e1.07) 17.1% 1.00 (0.95e1.07) 20�29 54.4% Referent 16.6% Referent 30�39 48.2% 0.81 (0.78e0.83) 13.8% 0.85 (0.82e0.89) 40�44 41.9% 0.63 (0.57e0.69) 12.9% 0.81 (0.71e0.93)

Ever resided in PCSA

Yes 53.2% 1.06 (1.03e1.09) 14.4% 0.76 (0.73e0.79)

No 51.5% Referent 18.2% Referent

Delivery method

Cesarean 49.1% 0.84 (0.81e0.86) 13.2% 0.77 (0.73e0.80)

Vaginal 54.1% Referent 16.9% Referent

CI, confidence interval; PCSA, primary care shortage area.

a Model adjusted for state-funded health care program (Medi-Cal Fee for Service, managed care, Family PACT) at 99 days.

Thiel de Bocanegra et al. Disparities in postpartum contraception. Am J Obstet Gynecol 2017.

ajog.org GYNECOLOGY Original Research

information on women’s health-related beliefs or contraceptive preferences, which may also vary by race/ethnicity.

HEDIS postpartum visit rates computed using administrative data rather than the hybrid method of chart reviews and administrative data are lower than rates supplemented with chart review27 and self-reported post- partum visits in the Pregnancy Risk Assessment Monitoring System (PRAMS).28,29 There is no reason, however, to believe reporting methods affect differences seen by race or ethnicity and using administrative data provides an efficient means to monitor postpartum contraception uptake.

States usually report postpartum visit rates using HEDIS reporting

requirements, which excludes women who switched managed care plans or disenrolled for other reasons and are less likely to return for postpartum visits.30

Our analysis shows the importance of monitoring postpartum visit and post- partum contraception rates for all women with a publicly-funded delivery to ensure optimal maternal child health. Health care encounters during the

postpartum period are an important opportunity to help ensure that future pregnancies are well-timed and healthy. Efforts to increase postpartum visit rates will need to address the multiple reasons that women do not make these visits, including education on the importance and benefit of returning postpartum. Text4Baby, a client-focused text service

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that sends prenatal and postpartum health messages to women,31 has pro- vided a novel approach to sharing such information. Hospital systems also can work on the scheduling of postpartum appointments that consider the infant’s pediatric appointments as well as the woman’s work schedule.

Concomitant with increasing the HEDIS postpartum visit rate, efforts are needed to increase provision of post- partum contraception before hospital discharge to ensure that women have access to their contraceptive of choice even if they are unable to return for further postpartum care. Several states (including California) have changed their policies to reimburse for maternity inpatient IUC and implant placement

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outside of a global delivery billing fee.32,33

In conclusion, significant racial/ethnic disparities exist among low-income Californian mothers’ likelihood of attending postpartum visits and receiving postpartum contraception and highly effective contraception. Healthy People 2020 includes a developmental objective to assess postpartum contra- ception (MCH16-6)34; in 2014, the Centers for Medicaid and CHIP Services initiated a pilot of technical specifica- tions for this measure among various state Medicaid agencies.35,36 Measures for postdelivery inpatient contraception (within 3 days after delivery) and post- partum contraception at sixty days have been endorsed by the National Quality Forum.37,38 To identify gaps and develop successful interventions, it will be important to calculate these measures by race/ethnicity, age, and place of residence to ensure equitable access to postpartum care. Identifying these disparities will support design and implementation of tailored interventions designed to address these disparities and will, ulti- mately, support the reduction of dispar- ities in maternal and infant health. n

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Author and article information From the Bixby Center for Global Reproductive Health,

Department of Obstetrics, Gynecology, and Reproductive

JULY 2017 Ame

Sciences, University of California, San Francisco (Dr Thiel

de Bocanegra, Ms Braughton and Bradsberry, and

Mr Howell); California Department of Health Care Ser-

vices, Medical Director’s Office, Sacramento (Dr Logan);

and Division of General Internal Medicine, University of

California, Davis (Dr. Schwarz), CA.

Received Sept. 17, 2016; revised Jan. 7, 2017;

accepted Feb. 24, 2017.

The authors report no conflict of interest.

This research was prepared by the University of

California, San Francisco (UCSF), Bixby Center for Global

Reproductive Health and was partially supported by the

State of California, Department of Health Care Services,

and the Centers for Medicare and Medicaid Services

under the Adult Medicaid Quality Grant, award number

1F1CMS331105. All analyses, interpretations, or

conclusions reached are those of UCSF, not the State

of California or Centers for Medicare and Medicaid

Services.

Corresponding author: Heike Thiel de Bocanegra,

PhD, MPH. heike.thiel@ucsf.edu

rican Journal of Obstetrics & Gynecology 47.e7