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Published in final edited form as: Am J Obstet Gynecol. 2021 Oct 13;226(3):394.e1–394.e16. doi: 10.1016/j.ajog.2021.10.009

Feasibility and Acceptability of a Toolkit-Based Process to Implement Patient-Centered, Immediate Postpartum Long-Acting Reversible Contraception Services

Michelle H MONIZ 1,2,3, Vanessa K DALTON 1,2,3, Roger D SMITH 1, Lauren E OWENS 1, Zach LANDIS-LEWIS 4, Alex F PEAHL 1,2,3, Barbara VAN KAINEN 1, Margaret R PUNCH 1, Marisa K WETMORE 1,2, Kirsten BONAWITZ 5, Giselle E KOLENIC 1,2, Christine DEHLENDORF 6, Michele HEISLER 7
PMCID: PMC8917096  NIHMSID: NIHMS1756585  PMID: 34655551

Abstract

Background:

National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (i.e., insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits—packages of resources and strategies to facilitate implementation of new services—are a promising approach for guiding clinical practice change.

Objective:

To develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing.

Study Design:

We conducted a single-site feasibility study of toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017–2020. Based on prior qualitative work, we developed a theory-informed implementation toolkit. A Stakeholder Panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (i.e., implementation leadership, planning and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018-April 2019. Study outcomes included implementation outcomes (i.e., provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (i.e., trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure].

Results:

Implementation Process: Among 172/401 (43%) of eligible clinicians participating in surveys, 70% were “extremely” or “somewhat” satisfied with the implementation process overall. Prenatal Contraceptive Counseling: Among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall across 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%−79%). Immediate Postpartum Long-Acting Reversible Contraception Utilization: Utilization increased across the study period (pre-implementation, 5.46% of deliveries; during implementation, 8.95%; post-implementation, 8.58%). Patient Experience of Contraceptive Care: Patient survey respondents (response rate 15–29%) were largely white (344/425, 81%) and highly educated (309/425, 73% with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67% to 63%; hospital, 45% to 58%; outpatient postpartum, 69% to 65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and to support a more patient-centered experience of contraceptive care.

Conclusion:

A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability, but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test effectiveness of the refined toolkit in a multi-site, prospective trial.

Keywords: postpartum contraception, long-acting reversible contraception, LARC, implementation, toolkit, quality improvement

Introduction:

National guidelines recommend that maternity systems provide access to immediate postpartum long-acting reversible contraception (LARC).1–4 Medicaid programs began reporting immediate postpartum LARC utilization as a national quality measure5,6 in the Centers for Medicare and Medicaid Services (CMS)’s Core Measure set in 2019,7 documenting very low rates of utilization (median 0.8%, range, 0.4–1.9%) across 29 states.8 A national sample of commercially insured individuals demonstrated similarly low utilization rates.9 Statewide work in Michigan,10 New Mexico,11 and South Carolina12 has demonstrated that many birthing hospitals do not offer immediate postpartum LARC care. Together, these data suggest that access barriers may prevent some interested individuals from initiating immediate postpartum LARC.13 However, healthcare systems face significant challenges to offering these services,14–18 and those attempting to implement evidence-based peripartum contraceptive services have achieved mixed success—highlighting the need for more effective implementation interventions.11,19–22

Patient-centeredness—a core domain of healthcare quality23—is another key outcome for contraceptive quality improvement (QI) efforts. The U.S. healthcare system has a history—including in contemporary practice—of limiting the reproductive autonomy of some people, including those living on low incomes and people of color.24–26 Additionally, multiple studies suggest that contraceptive care is affected by healthcare workers’ biases, sometimes resulting in failures to center patient needs and preferences and in patients feeling subtly or overtly pressured in their contraceptive decision-making.27–31

Implementation toolkits are one promising approach to improving peripartum contraceptive care quality. Implementation refers to efforts to embed evidence-based practices, such as immediate postpartum LARC access, patient-centered contraception counseling, and shared decision-making, into routine care delivery. Implementation may include activities to newly adopt or address underutilization of a recommended clinical practice. Toolkits are packages of resources to support clinical practice change and may include tools for informing institutional policy, training practitioners and staff, mapping workflow, and auditing performance to guide ongoing improvement efforts. A recent systematic review found that toolkits can effectively support efforts to integrate evidence-based clinical practices into routine care, but called for future toolkits to be a) informed by high-quality evidence and theory, and b) rigorously evaluated for acceptability and effectiveness.32

Multiple entities have released immediate postpartum LARC implementation toolkits.33,34 None to date, however, have been developed and evaluated using rigorous implementation science and behavior change theory. We aimed to develop a theory-informed toolkit, evaluate the feasibility and acceptability of toolkit-based implementation of patient-centered, immediate postpartum LARC services, and refine the toolkit for future effectiveness testing.

Methods

We conducted a single-site feasibility study of toolkit-based implementation of immediate postpartum LARC services. To guide toolkit refinements, we measured implementation process outcomes, including provider perceptions of implementation tools and the implementation process, and healthcare quality outcomes, including institutional trends in prenatal contraceptive counseling rates, immediate postpartum LARC utilization rates, and patients’ reported experience of contraceptive care. The study was approved by our institutional review board (HUM00126810) and registered on Clinicaltrials.gov (NCT03774797), though implementation studies are not clinical trials.

Setting:

The study site is a midwestern academic medical center with over 150 maternity providers (including over 60 resident physicians), over 250 maternity nurses, and approximately 4800 pregnant patients receiving care at 12 ambulatory clinics annually. Before implementation began, LARC devices were on the inpatient formulary but not routinely offered to all pregnant individuals. Prenatal contraceptive counseling was documented in progress notes, with no institutional capacity to measure counseling rates or patient contraceptive preferences.

Toolkit Development:

We previously conducted a qualitative multiple case study of immediate postpartum LARC implementation at 11 U.S. early adopter hospitals,18 where we collected implementation artifacts (e.g., clinical practice guidelines, provider training materials) and interviewed key informants during site visits. Data collection and analysis were informed by behavior change theories captured in the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementing Change.35,36 This prior work identified a menu of promising tools and strategies for optimizing local conditions for successful implementation of patient-centered contraceptive services for pregnant and postpartum individuals. Based on these findings, we generated a collection of resources in a publicly available online toolkit10 to guide the integration of immediate postpartum LARC services into widespread clinical practice. Appendix A summarizes a) key conditions for successful implementation, guided by the CFIR, and b) corresponding toolkit resources, including tools and strategies.

Implementation Process:

Study activities occurred over a three-year period from 2017–2020 (Figure 1). We convened a 22-person Stakeholder Panel that included midwives, family physicians, obstetricians, resident physicians, nurses, pharmacy and billing staff, and trained patient advocates to lead implementation efforts. The panel met regularly during 2017 and 2018 to plan implementation activities. To inform the panel’s work, MW and MHM conducted a series of key informant interviews with 11 providers and nine patients. Interviews were rapidly analyzed37–40 to identify local barriers and facilitators to immediate postpartum LARC implementation and patient preferences for care delivery. Panel members reviewed interview findings and selected tools and implementation resources to optimize local conditions for implementation. For example, to optimize clinician knowledge, skills, and attitudes (condition), the intervention included educational resources (tools) and mandatory education and simulation sessions (strategy). Selected toolkit tools and strategies were bundled into a multicomponent implementation intervention (Figure 2). The intervention was executed during January 2018-April 2019 and included clinician and staff training activities (e.g., Grand Rounds on national guidelines for patient-centered, evidence-based peripartum contraceptive care; post-placental IUD insertion simulation sessions); electronic medical record (EMR) modifications; adoption of new clinical protocols and processes for ordering, stocking, and billing for LARC devices; and dissemination of patient resources. Implementation evaluation activities occurred during 2019–2020. Formative focus groups (e.g., at division meetings and team huddles) helped identify care delivery workflow challenges and inform corresponding process refinements.

Figure 1.

Figure 1.

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Study timeline

Figure 2.

Figure 2.

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Implementation strategies and tools selected for a multicomponent intervention to increase provision of evidence-based peripartum contraceptive care

Outcomes:

We examined implementation and healthcare quality outcomes and toolkit refinements using provider and patient surveys and institutional administrative data (Table 1). Survey instruments—one each for providers and patients—were built in Qualtrics software, using validated measures where available. Experts in survey methodology, maternity care innovations, and our institution’s interdisciplinary Program on Women’s Healthcare Effectiveness Research pilot-tested and refined surveys prior to deployment.

Table 1.

Study outcomes

Outcomes Data Source Timing of Data Collection
Implementation Process
Perceptions of implementation tools and process Provider surveys Spring 2020
Healthcare Quality
Peripartum contraceptive counseling rate Electronic Medical Record January through December 2019
Immediate postpartum LARC utilization rate Electronic Medical Record January 2017 through Dec 2019
Patient experience of care Patient surveys Fall 2018; Spring 2020
Toolkit Refinements
Key modifications to toolkit resources Implementation process log Throughout implementation
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LARC=long-acting reversible contraception

Implementation process outcomes:

Provider perceptions of the implementation process and implementation tools were assessed via an online post-implementation survey (July 8-August 16, 2020). All maternity care clinicians (generalist obstetricians, Maternal Fetal Medicine and family physicians, certified nurse midwives, resident obstetrician-gynecologists, and inpatient maternity nurses) were invited to participate via email. Clinicians were reminded about institutional changes in peripartum contraceptive care and then asked about satisfaction with and usefulness of toolkit resources (Figure 3). Survey items invited clinicians to provide free-text responses about their perceptions.

Figure 3.

Figure 3.

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Provider survey questions

Healthcare quality outcomes:

Monthly prenatal contraceptive counseling rates (i.e., proportion of delivering individuals with documented counseling) were ascertained from EMR data in a standardized documentation element (Appendix B). This provided a feasible indicator of clinicians’ provision of a recommended service (i.e., prenatal counseling and documentation about a patient’s reproductive life goals and contraceptive method preferences). Immediate postpartum LARC utilization rates were ascertained by identifying LARC diagnostic and procedural codes in institutional administrative data (Appendix C). We measured monthly rates of LARC utilization (i.e., count of LARCs placed per total deliveries in a month) in three time periods: pre-implementation (January-December 2017), during implementation (January 2018-April 2019), and post-implementation (May-December 2019). We monitored these outcomes because the Office of Population Affairs designates LARC utilization rates as one tool for evaluating potential contraceptive access barriers.6 However, we recognized the limitations of utilization measures—where trends toward higher utilization could reflect removal of access barriers, but could also reflect non-patient centered care, where patients feel subtle or overt pressure to utilize contraceptive methods. We therefore also collected a balancing measure of patient-centeredness: the patient experience of peripartum contraceptive care, including whether individuals receive respectful care and the method they prefer, if any at all.41,42 We collected serial cross-sectional surveys of a convenience sample of pregnant and postpartum patients receiving care at the study site. We recruited approximately 100 pregnant and 100 postpartum individuals during each survey fielding period (early implementation: July-October 2018; post-implementation: February-July 2020) to provide at least 80% statistical power when testing for moderately-sized effects (Cohen’s D=0.40, odds ratio=2.0). All English-speaking adult patients receiving outpatient maternity care at our institution and meeting eligibility as pregnant (32+ weeks gestation) or postpartum (4–8 weeks post-childbirth) received up to three invitations (via email or telephone) to participate. The patient experience of care item was adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure,43 with input from its creating team, for use in peripartum populations (Figure 4).44 The measure is scored dichotomously (all items “excellent” vs. any non-“excellent” responses). Surveys assessed the patient experience of contraceptive care in three settings: prenatal visits (pregnant sample), the childbirth hospitalization (postpartum sample), and postpartum visits (postpartum sample).

Figure 4.

Figure 4.

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Patient survey questions

Toolkit Refinements:

An implementation process log was used to track key modifications to toolkit resources, guided by observations from the Stakeholder Panel and the authors’ interpretation of implementation process and healthcare quality outcomes.

Analysis:

Quantitative administrative data and survey responses were summarized using descriptive statistics. Survey results are reported for the total number of patients or providers answering each question.45 Using a rapid analysis approach, free-text responses from providers were qualitatively coded based on emerging themes by two authors (MM, MW), with input from additional authors (AFP, MH). Discrepancies were rare and discussed until consensus was reached. Provider ratings and free-text responses were visually merged into a joint display presenting mean quantitative scores for each category of toolkit resources and representative qualitative quotes.46 Contraceptive counseling rates were summarized monthly. Monthly immediate postpartum LARC utilization trends before, during, and after pilot implementation were compared using a simple interrupted time series analysis. This logistic regression contained months, time period indicators, and their interactions. Statistical analyses were performed using Stata (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC.).

Results:

Implementation Process Outcomes

Of eligible clinicians, 172/401 (43%) participated in surveys (physicians: 62/86, 72%; obstetrics and gynecology residents: 12/25, 48%; midwives: 20/33, 61%; nurses: 90/257, 35%), with 70% being “extremely” or “somewhat” satisfied with the implementation process overall. Clinician perceptions about toolkit resources are presented in Figure 5. Clinicians found trainings to be helpful, but also described being unaware of some of the content covered in trainings and resources provided. EMR tools were praised as easy to use and helpful. Strategic communications largely targeted physicians and midwives and were perceived as helpful by half of respondents, while more than half were unaware that institutional-level performance feedback had been disseminated. Only one in three respondents found distributed feedback helpful, and some sought individualized performance feedback. Perceptions of patient educational resources were similar, with half of respondents unaware of these tools and many describing uncertainty about how to disseminate them.

Figure 5.

Figure 5.

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Clinician perceptions of implementation toolkit resources and processes

Healthcare Quality Outcomes

Prenatal Contraceptive Counseling:

Among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall across 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (range 30–79% in Q4; Figure 6).

Figure 6.

Figure 6.

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Prenatal contraceptive counseling rates over time, by clinic, 2019

Immediate Postpartum LARC Utilization:

The overall proportion of individuals utilizing immediate postpartum LARC increased across the study period (5.46% of deliveries pre-implementation, 8.95% during implementation, 8.58% post-implementation). An increasing monthly trend in immediate postpartum LARC utilization was observed during implementation (0.35% monthly increase, 95% CI [0.18%, 0.53%], p<0.001). The pre-implementation and post-implementation monthly trends, however, were not statistically different from zero (Pre: 0.36%, 95% CI [−0.2%,0.9%], p=0.206; Post: 0.1%, 95% CI [−0.19%, 0.41%], p=0.474) (Figure 7).

Figure 7.

Figure 7.

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Immediate postpartum long-acting reversible contraceptive utilization rates, over time

Patient Experience of Contraceptive Care:

More eligible pregnant than postpartum individuals participated in surveys (2018: 26%, 117/459 pregnant vs 29%, 97/338 postpartum; 2020: 15%, 109/731 pregnant vs. 21%, 102/477 postpartum). Patient respondents were largely white (344/425, 81%) and highly educated (309/425, 73% with at least 4-year college degree), reflecting the study site population (Table 2). The proportion of respondents giving an “excellent” rating for all four items in the adapted Person-Centered Contraceptive Counseling measure was low in all settings in 2018 and 2020, with lower scores in the hospital setting (prenatal visits, 67%, 63%; hospital, 45%, 58%; outpatient postpartum, 69%, 65%).

Table 2.

Demographic characteristics of patient survey respondents

Characteristic 2018 Pregnant (n=117) 2018 Postpartum (n=97) 2020 Pregnant (n=109) 2020 Postpartum (n=102)
Age group
 18–24 13 (11.1) 11 (11.3) 5 (4.6) 4 (3.9)
 25–34 71 (60.7) 57 (58.8) 74 (67.9) 68 (66.7)
 35–44 32 (27.4) 20 (20.6) 24 (22.0) 25 (24.5)
 Unknown 1 (0.9) 9 (9.3) 6 (5.5) 5 (4.9)
Education
 8th grade or less 0 (0) 0 (0) 0 (0) 0 (0)
 Some high school, high school graduate, or GED 7 (6.0) 4 (4.1) 4 (3.7) 3 (2.9)
 Some college or 2-year degree 25 (21.4) 15 (15.5) 19 (17.4) 18 (17.6)
 4-year college degree 31 (26.5) 23 (23.7) 32 (29.4) 32 (31.4)
 More than 4-year college degree 53 (45.3) 46 (47.4) 48 (44.0) 44 (43.1)
 Unknown 1 (0.9) 9 (9.3) 6 (5.5) 5 (4.9)
Ethnicity
 Hispanic or Latino 2 (1.7) 7 (7.2) 4 (3.7) 4 (3.9)
 Not Hispanic or Latino/Unknown 115 (98.3) 90 (92.8) 105 (96.3) 98 (96.1)
Race
 White 99 (84.6) 72 (74.2) 90 (82.6) 83 (81.4)
 Black or African-American 7 (6.0) 7 (7.2) 4 (3.7) 5 (4.9)
 Asian 5 (4.3) 4 (4.1) 4 (3.7) 5 (4.9)
 All othera 6 (5.1) 14 (14.4) 11 (10.1) 9 (8.8)
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Data presented as n (%)

a

Includes Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, Other, Unknown, and patients choosing more than one race

GED=General Educational Development Test

Toolkit Refinements:

Refinements focused on generating additional resources to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care. We now provide a quarterly feedback report, with data on trends in prenatal contraceptive counseling and immediate postpartum LARC utilization rates and patient experience of care scores (now administered to all study site patients as part of routine QI efforts), with a goal of driving improvements in counseling rates and patient-centered care. The report also contains a “resource round-up” section reminding clinicians about educational materials to maintain knowledge and skills. The refined toolkit also incorporates multiple resources and strategies to optimize the patient experience of care. First, patient educational handouts are now automatically disseminated through the EMR’s after-visit patient instructions, based on gestational age. These materials now include a new shared decision-making tool, the MyBirthControl app,47–49 designed to improve the patient-centeredness of peripartum contraceptive counseling and decision-making. Second, we created a patient video about options for the timing of LARC insertion, to ensure that pregnant individuals interested in utilizing postpartum LARC methods receive comprehensive, accurate, and balanced information about trade-offs with immediate versus outpatient postpartum LARC insertion. Third, we developed additional training sessions for clinicians, including a Grand Rounds focused on the patient experience of care, reproductive justice, and findings from the current study, and annual training in immediate postpartum LARC for newly hired staff and trainees.

Comment

Principal Findings:

In this feasibility study at a single academic center, a toolkit-based process to implement evidence-based, patient-centered peripartum contraceptive services was associated with high clinician acceptability, but mixed healthcare quality outcomes: immediate postpartum LARC utilization increased; documented prenatal contraceptive counseling rates varied across ambulatory sites; and the patient experience of care remained poor. The refined toolkit thus now includes additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care.

Results in Context:

Our findings build on and extend prior studies with public health officials and healthcare systems to improve immediate postpartum LARC implementation in maternity settings.11,18,21,22,50–53 Implementation challenges have been documented; one study of 11 healthcare systems implementing immediate postpartum LARC programs found that sites utilized, on average, 18 distinct implementation strategies (range, 11–22).18 Another study of five sites found that immediate postpartum LARC implementation efforts cost, on average, $14,433.94 (range $9955.61–$23,690.49), with higher costs at sites with more barriers to implementation.50 An implementation toolkit may help increase the efficiency and effectiveness of implementation efforts. The current study’s findings support the feasibility and acceptability of our theory-based implementation toolkit. Healthcare workers were pleased with toolkit resources, especially clinician training and EMR tools. Study findings provide preliminary support for this theory-based toolkit’s effectiveness in improving the quality of peripartum contraceptive care. We observed an encouraging improvement in rates of documented perinatal contraceptive counseling across the study period—particularly in some high-performing clinics—and potentially enhanced access to immediate postpartum LARC for interested patients. Toolkit refinements to support ongoing clinician education, more effective patient education and engagement in shared decision-making, and more timely clinician performance feedback may help ensure that recommended practices (i.e., patient-centered prenatal counseling about postpartum contraception, and provision of immediate postpartum LARC to interested, eligible patients) are fully routinized and improve the patient experience of care.

Our findings underscore the importance of routinely monitoring the patient experience of contraceptive care as a key indicator of peripartum healthcare quality. The National Quality Forum recently endorsed the Person-Centered Contraceptive Care survey as a patient-reported outcome performance measure for use in tandem with claims-based measures of contraceptive utilization to monitor the quality of contraceptive care among reproductive-aged women. Our findings suggest the pressing need for this measure to be formally adapted and validated specifically in peripartum populations, as well as need for more robust processes to involve patients and families in maternity care QI efforts. Patients and family members provide a vital, unique perspective about the healthcare system and can significantly enhance the success of QI efforts.54

Clinical implications:

Improving contraceptive access and the patient-centeredness of contraceptive services are crucial activities for supporting people in achieving their reproductive and broader educational, professional, and economic goals. Our study’s findings highlight the importance of including patient-centered outcomes in evaluation of peripartum contraceptive care to ensure it is fully responsive to individual patients’ preferences and needs.

Research Implications:

Prospective, multi-site trials are needed to evaluate the effectiveness of toolkit-based multicomponent implementation interventions in heterogeneous contexts (e.g., academic centers, community-based hospitals, hospitals serving rural populations). In addition to monitoring trends in quality outcomes, future work should also evaluate the sustainability and costs of quality improvements achieved with a toolkit-based implementation process. Our findings call for the development and inclusion of validated measures of the patient experience of contraceptive care in any implementation intervention evaluation. If successfully executed, such implementation research may help drive improvements in peripartum contraceptive care quality. More broadly, such implementation research in maternity contexts may identify promising strategies to address adverse birth outcomes, including unacceptable inequities in these outcomes.55

Strengths and Limitations:

Key study strengths include the use of rigorous formative research and behavior change theory to inform toolkit design, a stakeholder-engaged process for selection of toolkit items, and evaluation of both implementation outcomes and preliminary quality outcomes. Additionally, this prospective study included measurement of the patient experience as a key indicator of peripartum contraceptive care quality. Limitations include a single-site study with a principal goal of assessing feasibility and acceptability. Both provider and patient survey findings are limited by low response rates. Finally, the study site’s patient population is largely white and college-educated, limiting generalizability in strict methodologic terms, but we believe still providing insights relevant to more diverse patient populations. The consistency of our observed patient survey outcomes suggests to us that something about our institution—our care delivery processes, our culture, our communication, and our interactions with patients—is undermining the patient experience of care. If this is true for our patient population—a largely resourced, highly educated group—we believe it suggests that circumstances may be equally bad or worse in marginalized populations more likely to suffer from interpersonal biases based on race or class and structural inequities like structural racism.

Conclusions:

Toolkit-based implementation of recommended postpartum contraceptive care was associated with provider acceptability, variable improvement in contraceptive counseling, increased immediate postpartum LARC utilization, and no improvements in the patient care experience. Toolkit modifications were made with a goal of optimizing contraceptive counseling and the patient experience of peripartum contraceptive care. A rigorous, fully-powered, multi-site trial of the refined toolkit’s effectiveness is now needed. Additional work is also needed to develop a validated measure of the patient experience of peripartum contraceptive care and to identify and promote the widespread adoption of best practices for involving patients and communities in perinatal care QI efforts.

AJOG At A Glance.

A. Why was this study conducted?

Implementation toolkits—packages of resources and strategies to facilitate organizational change—are promising but relatively understudied.

B. What are the key findings?

A toolkit-based process to implement immediate postpartum long-acting reversible contraception (LARC) services at a single academic center was associated with a) positive provider perceptions; b) increasing documented prenatal contraception counseling rates (2019: Q1, 12.5%; Q4, 51.0%); c) increased inpatient LARC utilization (pre-implementation, 5.46%, post-implementation 8.58%); and d) no improvement in the proportion of patients reporting an excellent experience of care (baseline vs post-implementation: prenatal visits, 67% vs. 63%; childbirth hospitalization, 45% vs. 58%; outpatient postpartum, 69% vs. 65%).

C. What does this study add to what is already known?

A toolkit-based process to implement immediate postpartum LARC was feasible and acceptable. A rigorous, fully powered trial of the refined toolkit’s effectiveness is needed.

Funding:

Dr. Moniz is supported by the AHRQ, grant #K08 HS025465. Dr. Heisler is funded by the National Institutes of Health (NIH), including Grant Number P30DK092926 (MCDTR) from the National Institute of Diabetes and Digestive and Kidney Diseases. The AHRQ and NIH played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

Conflicts of Interest:

Michelle Moniz is a paid consultant for RAND, NIDA, and the Society of Family Planning. Dr. Dalton has received grant funding from the Agency for Healthcare Research and Quality (AHRQ), American Association of Obstetricians and Gynecologists Foundation, the Laura and John Arnold Foundation, National Institute for Reproductive Health, Blue Cross Blue Shield of Michigan Foundation, the Society of Family Planning and the National Institutes for Health outside the submitted work. She is also a contributing editor for the Medical Letter and an author for Up-to-Date. She is also a consultant for Bind and expert witness for Merck. Christine Dehlendorf is an author for Up To Date. The remaining authors report no conflicts of interest.

Appendix A.

Overview of an Evidence-based Toolkit for Implementing Immediate Postpartum Long-Acting Reversible Contraception Services

Conditions for Successful Implementation1 Description1 Implementation Strategies1 Implementation Tools2
Effective Implementation Champions Effective champions use their influence in the organization, persuasiveness, grit, and participative leadership style to overcome institutional siloing, leverage professional networks, create tension for change, cultivate a positive learning climate, optimize workflows, engage key stakeholders, and lead implementation planning and evaluation processes. Clinical champions benefit from an interprofessional team of co-champions. Champions with competing demands on their time and insufficient support for project management may struggle to be effective. Identify and prepare champions
Build a coalition
Conduct local needs assessment
Assess for readiness and identify barriers and facilitators
Tailor strategies
Develop a blueprint
Obtain feedback about the implementation plan
Stage scale up
Facilitation
Plan for outcome evaluation
Develop processes for quality monitoring
Evaluate implementation 		Online Toolkit
Virtual Project Manager
Enabling Financial Environment Non-reimbursement by major payers or evidence of financial losses can undermine implementation efforts, while written policies or audits documenting public and private payer reimbursement for services facilitates implementation. Conduct local consensus discussions
Project financial implications
Access new funding
Place innovation on inpatient formulary 		Consensus Builder
Medicaid Billing Primer
Payer Advocacy Brief
Hospital Administrator Engagement Disengaged leaders may not provide permission and support for the initiative to proceed, while engaged leaders who perceive the initiative as aligned with their mission and vision can act as vocal sponsors who increase the initiative’s visibility and priority in the organization. Conduct local consensus discussions Consensus Builder
Trust and Effective Communication A lack of pre-existing relationships and communications processes across clinicians and operations staff may impede implementation success. Mistrust among individuals with divergent expertise, priorities, and reporting structures hamper communication and shared problem-solving. Conversely, strong relationships and robust communication norms across stakeholders promote collaboration necessary to address implementation challenges and ensure efficient frontline care delivery. Promote network weaving
Organize clinician and staff team meetings for shared problem-solving and accountability 		Communication Primer
Virtual Project Manager
Alignment with Stakeholders’ Professional Values Individuals perceiving the initiative as aligned with their professional mission and values are more likely to promote its success. Individuals seeing the initiative as at odds with professional values may resist change and significantly stall institutional progress. Conduct local consensus discussions
Project financial implications 		Consensus Builder
Perception of Meeting Patients’ Needs Perceptions that offering inpatient LARC services better meets patients’ needs strongly promotes provider and staff willingness to make services available to interested patients. Because multiple studies document real tensions between enhancing access to contraceptive care and ensuring that patients have a high-quality, patient-centered care experience, it is crucial to include patients in implementation planning and evaluation to ensure that care delivery changes are truly aligned with patient needs. Involve patients in implementation planning and evaluation
Prepare patients to be active participants
Engage community resources 		MyBirthControl App 3
Patient Informational Material (handouts, posters, educational videos)
Robust Learning Climate Robust learning climates, where providers and staff feel essential and empowered to shape change, catalyze implementation. Frontline providers and staff feel motivated to design new workflows, overcome challenges, and make real-time refinements to care delivery. Facilitation
Obtain stakeholder feedback
Create psychological safety
Make colleagues’ contributions visible 		Communication Primer
Compatibility with Workflow Embedding inpatient LARC into daily care delivery routines requires steps to minimize workflow disruptions, including establishing communication processes across teams and settings, making devices available, optimizing medical records for documentation and device ordering, and streamlining billing and coding processes. Prospectively designing these processes promotes success, while letting workflow evolve organically can lead to inefficiencies, introduce confusion and frustration, and cause interruptions to service provision to patients. Assess and redesign workflow
Obtain stakeholder feedback
Change record systems to streamline documentation
Change physical structure and equipment
Remind clinicians
Make billing easier 		Clinical Protocol
Consent Forms
Workflow Map Design Tool
Electronic Medical Record Tools (tipsheet, standardized documentation)
Knowledge, Attitudes and Beliefs About the Clinical Practice Providers may have significant knowledge and skill gaps, as many do not receive implant or post-placental IUD insertion training in residency. Providers with negative attitudes about the initiative can seriously undermine service delivery to patients and colleagues’ engagement in the initiative. Opinion leaders supportive of the initiative can strongly influence colleagues’ perceptions and motivation to participate. Dynamic training and education for clinicians and staff
Develop and distribute educational materials
Conduct ongoing training
Clinical supervision
Conduct clinician and staff team meetings
Engage local opinion leaders
Audit and provide feedback about performance 		Provider Training Tools (Grand Rounds slideset, pre-simulation didactic, nursing e-module, counseling FAQs, implant insertion supplies checklist, IUD insertion eligibility checklist)
Communication Primer
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Content based on findings in Moniz et al. Implementing Immediate Postpartum Contraception: A Comparative Case Study at 11 Hospitals, in Implementation Science Communications, 2021: https://implementationsciencecomms.biomedcentral.com/artides/10.1186/s43058-021-00136-7

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All tools are publicly available in an online toolkit at contraceptiveaccess.org

Appendix B.

graphic file with name nihms-1756585-f0008.jpg

graphic file with name nihms-1756585-f0009.jpg

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Appendix C.

Diagnostic and procedural codes used to identify immediate postpartum LARC utilization rates

Deliveries
ICD-9 Dx ICD-10 Dx
Include V27, V27.0, V27.1, V27.2, V27.3, V27.4, V27.5, V27.6, V27.7, V27.9, 650 Z37, Z37.0, Z37.1, Z37.2, Z37.3, Z37.4, Z37.5, Z37.59, Z37.6, Z37.69, Z37.7, Z37.9, 080
Exclude 630, 631, 632, 633, 633.0, 633.00, 633.01, 633.1, 633.10, 633.11, 633.2, 633.20, 633.21, 633.8, 633.80, 633.81, 633.9, 633.90, 633.91, 634, 634.x, 635, 635.x, 636, 636.x, 637, 637.x, 638.x, 639, 639.0, 639.1, 639.2, 639.3, 639.4, 639.5, 639.6, 639.8, 639.9, V24, V24.0, V24.1, V24.2 A34, O00, O00.0, O00.00, O00, O00.1, O00.2, O00.8, O00.9, O01.9, O02, O02.1, O03, O03.0, O03.1, O03.2, O03.30, O03.31, O03.32, O03.33, O03.34, O03.34, O03.39, O03.4, O03.5, O03.6, O03.7, O03.8x, O03.9, O04.5, O04.6, O04.7, O04.8x, O07.0, O07.1, O07.2, O07.3x, O07.4, O08.0, O08.1, O08.2, O08.3, O08.4, O08.5, O08.6, O08.7, O08.81, O08.83, O08.89, O08.9, Z33.2, Z39, Z39.0, Z39.1, Z39.2
ICD-9 Px ICD-10 Px
Include 72, 72.x, 73, 73.01, 73.09, 73.1, 73.2, 73.21, 73.22, 73.3, 73.4, 73.5, 73.51, 73.59, 73.6, 73.8, 73.9, 73.92, 73.93, 73.94, 73.99, 74, 74.1, 74.2, 74.4, 74.9, 74.99 0Q820ZZ, 0Q823ZZ, 0Q824ZZ, 0Q830ZZ, 0Q833ZZ, 0Q834ZZ, 0U7C7ZZ, 0W8NXZZ, 10A07ZZ, 10A08ZZ, 10D00Z0, 10D00Z1, 10D00Z2, 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10E0XZZ, 10J07ZZ, 10S07ZZ, 10S0XZZ, 10900ZC, 10903ZC, 10904ZC, 10907ZA, 10907ZC, 10908ZA, 10908ZC, 3E030VJ, 3E033VJ, 3E040VJ, 3E043VJ, 3E050VJ, 3E053VJ, 3E060VJ, 3E063VJ, 3E0DXGC, 3E0P7GC
Exclude 69.01, 69.51, 74.91, 75.0 N/A
DRG CPT
Include 370, 371, 372, 373, 374, 375
765, 766, 767, 768, 774, 775, 766		 59400, 59409, 59410, 59610,59612, 59614, 59510, 59514, 59515, 59618, 59620, 59622
Inpatient LARC
ICD-9 Dx ICD-10 Dx
Include V25.11, V25.13, V25.5 Z30.430, Z30.433, Z30.431, Z30.8
ICD-10 Px
Include 0UH97HZ, 0UH98HZ, 0UHC7HZ, 0UHC8HZ, 0UH90HZ
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Dx=Diagnosis codes, Px=Procedure codes; DRG=Diagnosis Related Group codes; CPT=Current Procedural Terminology codes; NDC=National Drug Code codes; HCPCS= Healthcare Common Procedure Coding System codes; LARC=long-acting reversible contraception

Footnotes

Condensation: Toolkit-based implementation of postpartum contraception care was associated with provider acceptability, variable improvement in contraception counseling, increased immediate postpartum LARC utilization, and no improvement in patient care experience.

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