Bob Kronemyer

Since 2012, when South Carolina's Medicaid program became the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (LARC) from global maternity payment, a significantly greater number of mothers are using LARC, especially among adolescents.

“For adults, this increase was accompanied by a decrease in tubal ligation, so the policy did not actually increase overall use of the most effective methods of contraception, like tubal ligation, intrauterine devices (IUDs) and implants,” said Maria Steenland, SD, a health scientist and research assistant professor of maternal and reproductive health policy at Brown University in Providence, Rhode Island. “However, for adolescents, the policy increased overall use of the most effective methods of contraception.”

Steenland is principal investigator of a study of LARC use in South Carolina, before and after the policy change, published in the journal 

“As recently as about 10 years ago, there were a lot of policy-related barriers to LARC access in the United States, and relatively few women used LARC methods,” Steenland told 

. “For immediate postpartum LARC, lack of separate payment was considered to be a major barrier, so understanding how removal of reimbursement-related barriers to immediate postpartum LARC provision affects the availability of these methods is an important policy question.”

The authors obtained all Medicaid claims data from South Carolina for inpatient, outpatient and pharmacy services from 2010 to 2014. For each childbirth, they measured the method of postpartum contraception.

Before the start of the policy change, 59% of births were followed by no most effective or moderately effective method of contraception in the 8 weeks after delivery.

Short-acting methods were the most common postpartum method choice, embraced by roughly 22% of mothers, followed by 13% sterilization.

Although 7% of births were followed by a postpartum outpatient LARC method, immediate use of this method was adopted by less than 1% of mothers.

Furthermore, postpartum LARC placement was concentrated in only five facilities in South Carolina. Among the 42 facilities conducting deliveries in the state, 57% had no patients with immediate postpartum LARC insertions after the policy change, and an additional 31% provided immediate postpartum LARC after fewer than 1% of births. 

The remaining facilities offered an immediate postpartum LARC to between 1% and 20% of women.

“Before the study, I had not thought very much about the counterfactual for women who adopt a LARC,” Steenland said. “I had assumed that an increase in postpartum LARC adoption would lead to an increase in use of highly effective methods and a decrease in short birth intervals. But the effect of an increase in immediate postpartum LARC on use of the most effective methods depends on the type of method that women would have used without the policy.”

Steenland noted the motivation for immediate postpartum LARC payment should be to expand patient choice rather than reduce pregnancy and health system costs. “Ultimately, this is a service that Medicaid pays for in outpatient settings, and if offering the service before leaving the hospital better meets some patient's needs, then it makes sense to make this service available,” she said.

Incomplete payments from Medicaid, such as reimbursement for some but not all of the immediate postpartum LARC provided, is a major concern of providers, according to Steenland. “Whether this results from hospital billing errors or Medicaid payment practices, the consistency of this finding indicates that earlier investment in creating and disseminating clear billing guidelines and making sure that the billing system can accommodate these changes is critical,” she said.

Because the upfront cost of purchasing LARCs is high, “any doubt about prompt and complete reimbursement could make hospitals reluctant to start to provide this service,” Steenland said.

Steenland reports no relevant financial disclosures.

Steenland MW, Pace LE, Sinaiko AD, et al. Medicaid payments for immediate postpartum long-acting reversible contraception: evidence from South Carolina. 

Articles

Medicaid payments for immediate postpartum LARC

A study of 30 women who had their post-cesarean section abdominal wall endometriomas (AWE) surgically removed found that the main symptom for detection and for surgery in two-thirds of cases was cyclic pain, whereas 13.3% of patients had no symptoms.

The average patient age was 35 years (range 25 to 55 years) in the cohort study in the 

. On average, the interval between prior cesarean section and appearance of symptoms was 55.2 months and the mean size of the excised mass was 42 mm.

Principal investigator Abdulkarim Hasan, MD, a consultant and lecturer of pathology at Al-Azhar University in Cairo, Egypt, said, “The rate of cesarean sections has been increasing steadily in our country and has reached an alarming level in recent years.”

In addition, the prevalence of cesarean section-associated complications, including AWE, increases with each additional operation, Hasan told 

All study patients were diagnosed, treated and followed for 2 to 8 years at Al-Azhar Hospital between January 2012 and November 2018. Surgical excision of AWE was performed by either a general surgeon or a gynecologist and most patients were not preoperatively examined by the pathologist.

For the study period, the incidence of AWE among patients with previous cesarean delivery was 0.21%.

The study found that preoperative AWE via fine-needle aspiration (FNA) cytology was performed in only 10% of cases, which helped exclude other potential pathologies.

One surprise study finding was that one patient experienced AWE 10 years after a previous cesarean section.

The mean excised mass size of 42 mm in the study was also much larger than the average size in previous similar pee-reviewed studies, “suggestive of late diagnosis,” Hasan said. But no recurrence occurred for excised masses with surgical margins less than 9 mm.

“Wide surgical excision with a margin of less than 1 cm could be acceptable, especially in cases of weak abdominal wall,” Hasan said.

The clinical-pathological agreement value for detection of the nature of the abdominal wall mass was 93.4%.

“Only AWE with high suspicion of another serious pathology should undergo preoperative cytological biopsy to exclude alternative diagnosis, but this procedure might exacerbate lesions progression, so good correlation between the surgical history and the ultrasonographic findings is crucial for preoperative diagnosis,” Hasan said.

To reduce the severity of post-cesarean section AWE, Hasan recommends that patients commit to regular follow up, have an early and accurate diagnosis, a preoperative radiological diagnosis rather than interventional tools, and a postoperative histopathology examination.

Similarly, to reduce the incidence of complications from the surgical removal of AWE, the authors advocate minimizing contact of swabs for cleaning the endometrial cavity within the scar site and removing the swabs quickly from the operation area. Also, avoid using the same suture material for closure of the uterus, saline wash the scar site before closing and suture the scar site thoroughly. “These steps may assist in preventing the growth of endometriotic tissue from the scar tissue,” Hasan said.

For future studies, Hasan advocates gene expression profiling of endometriosis and histological assessment of endometriotic fibrosis. He also supports evaluating the surgical margins for AWE in a larger number of cases for adopting generalized surgical recommendations.

Hasan reports no relevant financial disclosures.

Hasan A, Deyab A, Monazea K, et al. Clinico-pathological assessment of surgically removed abdominal wall endometriomas following cesarean section. 

. 2021 Jan 21;62:219-224; doi:10.1016/j.amsu.2021.01.029

A study of 30 women who had their post-cesarean section abdominal wall endometriomas (AWE) surgically removed found that the main symptom for detection and for surgery in two-thirds of cases was cyclic pain, whereas 13.3% of patients had no symptoms. 

Clinico-pathological assessment of post-cesarean section abdominal wall endometriosis 

Journal of Assisted Reproduction and Genetics

) calculated the rate of fetal anomalies detected on anatomy ultrasound in pregnant patients who underwent in vitro fertilization (IVF) with PGT-A, compared to patients who conceived following IVF with unscreened embryos and age-matched patients with natural conception.

“PGT-A has been increasingly used in IVF cycles in the United States, with reported use in over 40% of cycles in 2018,” said principal investigator Carrie Riestenberg, MD, a reproductive endocrinology and infertility specialist at Reproductive Partners Medical Groups in Redondo Beach, California. “However, while PGT-A is a valuable tool, its utility is frequently misunderstood by doctors and patients alike.”

A previous survey conducted at a high-volume academic IVF practice found that for the majority of patients, their primary reason for pursuing PGT-A was to increase the chance of having a “healthy baby,” and many other patients indicated it was to reduce the risk of birth defects.

“But the few studies that have investigated if PGT-A actually reduces the risk of birth defects have not had this conclusion,” Riestenberg told 

. “Our goal was to add to the body of literature on PGT-A and the risk of congenital anomalies.”

The current study, which Riestenberg and colleagues conducted at her high-volume maternal-fetal medicine practice in Los Angeles, consisted of patients with singleton pregnancies who had a mid-trimester anatomy ultrasound between January 2017 and December 2018.

A total of 712 patients who conceived after IVF, with or without PGT-A, were age-matched with natural conception controls.

The percentage of sonographic major abnormalities were 3.8% for natural conception, 4.2% for IVF without PGT-A and 3.8% for IVF and PGT-A.

For minor abnormalities, the percentages were 10.1%, 11.9% and 12.2%, respectively.

Rate of abnormal nuchal translucency, high-risk noninvasive prenatal testing (NIPT) and abnormal invasive diagnostic testing were also similar between IVF and natural conception patients.

However, patients who conceived after IVF, with or without PGT-A, had significantly higher rates of abnormal placental ultrasound findings compared to natural conception controls: 8.8% for IVF with PGT-A and 8.9% for IVF without PGT-A vs. 2.9% for natural conception (

Likewise, patients with natural conception had a significantly lower rate of abnormal second trimester serum analytes than the other two groups: 0.9% vs. 4.5% for IVF with PGT-A and 3.5% for IVF without PGT (

“Our finding that the use of PGT-A was not associated with a difference in the rate of fetal anomalies detected on mid-trimester ultrasound was not surprising, given that two-thirds of congenital anomalies are of unknown etiology and would therefore not be expected to be detected by PGT-A,” Riestenberg said.

The results of the study highlight the importance of patient counseling as to the limitations of PGT-A and of providing standard prenatal care for pregnancies conceived through assisted reproductive technology (ART).

Riestenberg reports no relevant financial disclosures.

Riestenberg CK, Mok T, Ong JR, et al. Sonographic abnormalities in pregnancies conceived following IVF with and without preimplantation genetic testing for aneuploidy (PGT-A). 

. Published online February 3, 2021. doi:10.1007/s10815-021-02069-5

Preimplantation genetic testing for aneuploidy (PGT-A) is not associated with a difference in risk of fetal anomaly detected on mid-trimester anatomical survey, according to a study.

Sonographic abnormalities in pregnancies after IVF

 that interviewed pregnant women and their partners on future potential uses of noninvasive prenatal testing (NIPT) found that 0% favored using the technology for non-medical sex selection and only 9% for determining non-medical traits.

In contrast, 97% approved NIPT for paternity testing, 55% for fetal whole genome sequencing (FWGS) to ascertain the child’s future risk of developing certain conditions at birth or during childhood, and 19% for FWGS to predict the child’s future risk of developing certain conditions during adulthood.

The qualitative study was conducted between October 2014 and August 2015 in both Lebanon and Quebec, Canada, as case studies to explore the impact of cultural differences on these views.

A total of 43 individuals participated in the interviews: 7 Quebecois couples; 8 Quebecoise women; 6 Lebanese couples; and 9 Lebanese women.

The pregnant women were either at low or high risk of having a child with trisomy 21, the most common chromosomal anomaly in humans.

To ensure study feasibility and contain a homogeneous sample in both cultural contexts, only heterosexual couples were included.

The study found that participants from Lebanon (n = 21) and Quebec (n = 22) answered similarly for four of the five proposed NIPT usages. But for FWGS to test for adult-onset conditions, five in the Lebanon group approved, while only three in the Quebec group.

“Our results can further inform the debate on the future uses of NIPT and future policy of its implementation,” said co-principal investigator Hazar Haidar, PhD, a lecturer in bioethics at Université du Québec à Montréal (UQAM), Montréal, Canada.

Based on the authors’ previously published research, Haidar expected to find more differences between the two groups because of the diverse cultural, social and policy backgrounds of each setting. “We had also noticed in the past significant differences in the factors affecting pregnant women’s decision-making whether to accept or reject NIPT,” she said.

Another surprise finding was the mention of religious reasons by participants in Quebec for their disapproval of NIPT for non-medical sex selection and non-medical traits. “Unlike Lebanon, religion in Quebec is not integrated into every day and political life,” Haidar said.

A healthcare professional’s awareness of a couple’s cultural and social background, such as the importance the couple places on involving family members in these decisions and/or on the clinician’s recommendation, “might better prepare and equip the healthcare professional to help the couple in making a decision, and therefore to offer them culturally sensitive and patient-centered care,” Haidar said.

As NIPT technology evolves, the debate surrounding its expansion beyond chromosomal abnormalities is becoming more and more pressing, according to Haidar. “Therefore, it is crucial to consider developing professional guidelines on the future uses of NIPT to aid clinicians in better navigating the medical and ethical complexities raised by the technology,” she said.

Engaging key stakeholders, such as disability rights advocates, people living with disabilities, policymakers and prospective parents, is also key.

“Education, support, and counseling for pregnant women and prospective parents to ensure they are making an informed reproductive decision when choosing whether or not to accept NIPT for a specific condition, and one that is congruent with their own values and preferences, are essential as well,” Haidar said.

Haidar reports no relevant financial disclosures.

Haidar H, Clerc-Blain JL, Vanstone M, et al. A qualitative study of women and partners from Lebanon and Quebec regarding an expanded scope of noninvasive prenatal testing. 