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LARC is the Word!

Posted By Brittni Frederiksen, Friday, December 11, 2015
Updated: Friday, December 11, 2015
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The buzzword in the Maternal and Child Health and Reproductive Health communities is LARC – long-acting reversible contraceptives (e.g. intrauterine devices (IUDs) and implants). LARCs are game-changing, highly effective contraceptive devices that can decrease unintended pregnancies and increase birth spacing. They are also cost-effective and require little effort on the part of the user, making them an appealing contraceptive method to both teens and adult women.


As a CDC/CSTE Applied Epidemiology fellow in Maternal and Child Health (MCH) in the Bureau of Family Health at the Iowa Department of Public Health (IDPH), I have had the opportunity to work on a number of projects related to LARCs. Iowa’s involvement in LARC-related initiatives started when Iowa and Colorado were funded by a private donor to lead Initiatives to Reduce Unintended Pregnancies by promoting LARC use and removing barriers to uptake. The Iowa Initiative grant allowed clinics to expand hours and locations, train clinical nurse practitioners and physicians on the benefits of LARCs and how to use them, and most importantly, purchase LARCs so clinics could offer them at low cost or no cost to their patients. LARCs are expensive upfront, and prior to the Iowa Initiative it was difficult for clinics to afford to offer LARCs to their patients because of the cost. During the Iowa Initiative period, use of LARCs as a primary method of contraception increased substantially while the percent of unintended pregnancies declined by 11% and pregnancies terminated by abortion declined by 25%. Even though the Iowa Initiative ended in 2012, LARCs have continued to remain a popular contraceptive choice for women in Iowa.


Over the past year Iowa has participated in a multi-state LARC Learning Community led by the Association of State and Territorial Health Officials (ASTHO). This initiative is designed to assist states in the implementation of immediate post-partum LARC insertion. In other words, strategies to provide women with a LARC before her hospital discharge, post-delivery. Immediate post-partum insertion of LARCs allow women to prevent unintended pregnancies and effectively space pregnancies. This in turn can decrease poor health outcomes for mothers and babies. One of the barriers to immediate post-partum LARC insertion has been the bundling of the post-partum insertion in the delivery payment. Bundled reimbursement prevented providers from getting reimbursed for the LARC device and insertion. In February 2014 Iowa Medicaid Enterprise released an informational letter no. 1349 to unbundle LARCs from the payment for the inpatient admission associated with the delivery. This was a significant step in promoting immediate post-partum LARC insertion. We were fortunate to have the opportunity to work with two Harvard students that visited IDPH for a week in January. We created an evaluation plan so that we can evaluate the effectiveness of the LARC unbundling as well as a proposed outreach and training program to educate providers, billing staff, and Medicaid recipients about insertion and billing of LARCs in the immediate post-partum period.


To ensure women have access to quality family planning services and to encourage use of the more effective contraceptive methods, the Office of Population Affairs has proposed two performance measures: The percentage of women aged 15-44 years at risk of unintended pregnancy that adopts or continues use of:

  1. The most effective (i.e., male or female sterilization, implants, IUDs) or moderately effective (i.e., injectables, oral pills, patch, ring, or diaphragm) FDA-methods of contraception
  2. An FDA-approved, LARC.

The first measure is an intermediate outcome measure, and it is desirable to have a high percentage of women who are using the most effective or moderately effective contraceptive methods. The second measure is an access measure, and the focus is on making sure that women have access to LARC methods. These two measures applied to women who have had a live birth are also in development to measure postpartum contraceptive use among women ages 15-44.


Iowa has had the unique opportunity to collaborate with the Office of Population Affairs and the Centers for Disease Control and Prevention to pilot the two performance measures using Title X data and Medicaid paid claims data. As a CDC/CSTE Applied Epidemiology fellow, I was able to apply my SAS programming skills to develop SAS code to calculate the performance measures using Medicaid claims data that other states can also use to calculate the measures among their Medicaid populations. The Center for Medicaid and CHIP Services (CMCS) recently awarded 13 states, including Iowa, and one US territory funding to support state efforts to collect and report data to CMCS on the new developmental quality measures to assess progress on their Maternal and Infant Health Initiative goal to increase the use of effective methods of contraception among all women in Medicaid and CHIP. This has been an incredible opportunity to apply my epidemiological skills to a national initiative that will ensure women have access to the contraceptive method of their choice while reducing unintended pregnancies and improving birth outcomes.

Brittni Frederiksen is a CDC/CSTE Applied Epidemiology fellow at the Bureau of Family Health in the Iowa Department of Public Health. For more information on related issues, join the CSTE Maternal and Child Health Subcommittee to follow updates on current activities.

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