Stakeholder partnerships were identified as a cross-cutting domain emphasized by states as a critical component required to implement strategies in all other domains. Most often, state teams implemented partnership-focused strategies within the domains of payment streams and reimbursement (8 of 13 states) and provider training (7 states; data not given). As payment streams and reimbursement changes require the partnership and support of the state health department, clinical facilities, device manufacturers, and insurers including the state Medicaid agency, the cross-cutting strategy of stakeholder partnerships was necessary to assure policy implementation throughout a state. Strategies included consistent communication with insurers, primarily Medicaid and Medicaid Managed Care Organizations, to implement changes in encounter rates, fees, and reimbursements (Table 3). State teams also developed strategies to partner with other in-state programs, identify state initiatives that promote health outcomes linked to improved contraceptive use (infant health, etc.), and better engage executive leadership of facilities to enhance policy implementation. One state described how partnership was essential in implementing a statewide process in facilities:

I’m wondering, if [to] make this commitment go to a larger number of hospitals that are actively doing this—that’s why I’m glad we had a presentation last week where the CEOs were in the room. It’s almost like you need to have that administrative clinical partnership for it to work. You need the clinical champion, and you need a senior person in a hospital that are working together. As we go back out now, hopefully, it’ll be easier for us to get the other partners, other people in the room, so to speak, that will need to make sure this happens in the hospital, so the coding folks get a comfort level. We work with the pharmacy folks to figure out the best way to make it easy for access, and we have a strong clinical champion that’s driving that forward.

Stakeholder partnerships provided additional opportunities to enhance education and training of providers in immediate postpartum LARC insertion. State teams described engaging national clinical membership organizations to support information and resource sharing for state and facility clinical champions (Table 3). One state team described how provider champions in the state are well-positioned to engage stakeholders across various settings:

Our main clinical champion [is] our chair of the state ACOG [chapter], a professor, and the Medicaid medical director. She has great reach through those different professional streams.

State teams partnered with academic institutions to promote provider training in teaching hospitals and collaborated with nonprofit agencies to obtain resources for provider training in facilities.

A range of activities were developed to support provider training, including skill-building activities for specialists, subspecialists, and nonclinical staff on topics ranging from IUD insertion techniques on the immediate postpartum uterus to accurate administrative and pharmacy billing and coding (Table 3). Implementation strategies for strengthening clinical practices consisted of hands-on training using pelvic models and simulators, providing resources to clinical staff addressing misperceptions about LARC safety and effectiveness (e.g., US MEC, US Selected Practice Recommendations for Contraceptive Use [US SPR], and the Recommendations for Providing Quality Family Planning Services [QFP]), and telehealth training for remote service provision.^8,36,37 State teams noted the relationship between well-trained providers and patient outcomes:

Making sure that residents and clinicians are well trained in LARC placement postpartum is something that we really want to focus on because of the connection with expulsion rates of LARC, and the experienced providers or clinicians having lower expulsion rates.

Many state teams emphasized identifying and engaging provider champions to disseminate tools and information on immediate postpartum LARC in facilities. State teams also acknowledged the importance of champions in clinical and nonclinical roles to support the implementation of immediate postpartum LARC policies:

It seems like every hospital that we work with should have a physician champion and then an administrative, roll up their sleeve person to drive the real work.

State teams described outreach as the recruitment of stakeholders supportive of immediate postpartum LARC policy implementation, and an increase in communication activities engaging the public on LARC. Teams focused on identifying internal stakeholders at birthing facilities, addressing stakeholder misperceptions about LARC methods, developing toolkits on implementation of LARC policies, and disseminating resources to assist with client conversations during prenatal care visits (Table 3). State teams also shared resources on the safety and effectiveness of contraceptive methods for postpartum women to providers and hospital staff, as expressed by one state team:

We proactively provided people with the CDC’s Medical Eligibility Criteria with a practice recommendation that really do support an immediate post-placental, postpartum placement even if that’s not what the [product label] says…we also have some literature that can also reinforce those conversations to make that process a little bit easier.

Some state teams focused outreach efforts on public health education programs and social media campaigns. One state team described engaging women from a specific region of the state in focus groups to discuss perceptions of LARC methods, then providing feedback to the local facility:

One thing that we’re working on very closely with the other areas, is what are the myths that surround LARCs and what can we do to address those and educate the population…we conducted a focus group with 22 women in the valley. It was quite astonishing the myths that surround LARCs right now, and shows how much work we have to do.

State teams emphasized strategy development for identifying streamlined processes for facility and provider reimbursement of contraceptive devices and insertion fees. Teams approached the reimbursement process in two ways: (1) developing resources for understanding the process of reimbursing for services, and (2) engaging insurers and manufacturers in discussions about service costs (Table 3). To understand current processes, state teams developed resources, clarification letters, policy memoranda, and medical bulletins to explain device purchase, inventory, coding, and reimbursement for devices in facilities:

Our ACOG president [has] been sending out bulletins and sort of spotlight[ing] on Medicaid. As soon as we finish this LARC one-pager about how to order, what’s the reimbursement, what’s the coding, what do the pharmacies buy, each of the five health plans…we’ll send it to every member. It’s just a lot for a provider to understand.

Some state teams described piloting resources, including billing and coding protocols or toolkits, in one or more facilities before promoting use among all facilities. Once current processes were understood, state teams recommended changes to the system by collaborating with the state Medicaid agency or managed care organizations to identify carve-in or carve-out populations for services, negotiate capitation rates for device purchases, develop state plan amendment language, and engage provider champions to facilitate clinical discussions. One state team described the process of working with the state Medicaid agency in detail:

Once we get CMS [Centers for Medicare and Medicaid Services] approval—we will be required to get CMS approval on the SPA [State Plan Amendment] change in order to carve out these devices from our inpatient hospitals. Once we get those and the methods of payment associated, we are really gonna strongly depend on our colleagues at [the health department] to help us inform those champions and those providers on how to actually do the billing. We also recognize that we’re gonna have to work with administration and hopefully the pharmacies at these facilities, too.

State teams focused on strategies to access the data necessary to measure uptake of immediate postpartum LARC in facilities, develop quality assurance and improvement indicators, and evaluate policy implementation efforts. Many states worked with the state Medicaid agencies to ensure access to Medicaid claims data at the state level. State teams proposed linkage of claims data to other data systems to provide the basis for examining associations between contraceptive use and other maternal and child health outcomes such as birth spacing, unintended pregnancy, Neonatal Intensive Care Unit (NICU) admissions, or preterm birth (Table 3). For those state teams with challenges to accessing administrative claims data, other proxy measures were identified to measure policy uptake (e.g., number of providers trained in LARC insertion, number of facilities providing immediate postpartum LARC):

We recognized early on that our baseline data couldn’t be the number of IUDs and implants placed because we just weren’t there yet…Our approach was to collect on other things that might show some sort of progress or forward movement on that idea of implementing at the institutional level. How many places have gotten through the pharmacy? What percentage of clinicians who can deliver at your institution have also received training? Similar kind of data point for nurses who are on Labor and Delivery [L&D]? What kind of other stakeholders will be directly involved and need to have some elements of training? Those kinds of things.

Many state teams initiated cost benefit and effectiveness analyses. Several states established data work groups to analyze or evaluate data outcomes:

We have our own internal experts really looking at the number of births that didn’t happen and the effects of those births that didn’t happen on other public support programs, like Special Supplemental Nutrition Program for Women Infants Children [WIC], TANF [Temporary Assistance for Needy Families], Childcare Assistance Program. We have about eight different programs we’re looking at some cost avoidance analysis on.

The domains of stocking and supply of devices, service locations, and informed consent were not identified as domains with large numbers of strategies, but were considered important areas of focus for further strategy development by state teams (Table 2).

Provider champions (e.g., clinical, nonclinical, or change agents with the knowledge, experience, and training to support applying evidence into practice)⁴² in a health setting were described as a ‘‘driving force behind the implementation’’ of activities or policy changes promoting favorable perception of particular clinical practices necessitating organizational change.^43–47 State teams identified champions as necessary for strategy implementation in all domains except informed consent, and data, monitoring, and evaluation, indicating a critical need. In the context of the LC, these providers championed device purchasing at facilities, led LARC insertion training and information sharing on best practices, worked with provider groups to increase uptake of immediate postpartum LARC in facilities (e.g., residency programs in teaching hospitals), and garnered buy-in from hospital administration. Champions were noted to function at two different levels—state and facility. State-level champions built administrative consensus to implement immediate postpartum LARC practices statewide, whereas facility-level champions utilized professional credibility and standing within facilities to establish protocols addressing institutional barriers.^48–51

Some state teams tested strategies before statewide implementation through single-site pilot testing. Teams partnered with single facilities to develop protocols to define, test, and adapt key processes, including reimbursement and stocking and supply strategies. State teams expanded on these approaches by developing pilot protocols adapted for smaller and rural facilities and clinics focused on provider training, reimbursement for services, and availability of devices, which were identified as barriers in previous studies.^30,52,53 In addition, state teams developed indicators of immediate postpartum LARC uptake, evaluating facility administration perceptions of provider experiences, and conducting cost projection, benefit, and effectiveness analyses. Results were disseminated statewide in toolkits for other facilities to use in policy implementation.

Only half of state teams described efforts focused on stocking and supply of devices, six focused on strategy development for rural or smaller facilities, and two implemented efforts on client-centered counseling and informed consent. The high and increasing cost of devices are institutional barriers to stocking devices at facilities,^54,55 which in turn may influence contraceptive counseling strategies and provision.^56,57 Not surprisingly, providers are less likely to counsel clients on contraceptive methods that are not available at their clinic location or through referral networks.⁵⁸ To encourage adequate stocking of LARC devices in facilities, state teams engaged facility pharmacies to add LARC to inpatient formularies, leveraged relationships with providers to promote stocking in hospitals, developed protocols for hospital staff on medication ordering and purchasing procedures, and encouraged hospital administration to stock LARC proximal to maternity units. Administrative and logistical issues like stocking and supply may be next steps in the implementation process, as only states successfully working in almost all other domains were focused on this area.

Beeson et al. identified evidence of limited access to contraceptive implants in rural areas.³⁰ Access to contraception in rural areas may be influenced by the training and capacity of clinic staff (e.g., presence of an obstetrician/ gynecologist), funding mechanisms (e.g., earmarked family planning funding), and patient knowledge and acceptance of contraceptive methods.^30,52 In some states, limited opportunities to interact with the health care system may influence women’s decisions to use highly effective contraceptive methods.⁵⁹ To increase contraception access for specific populations including services in rural or remote areas, teams leveraged existing residency programs to provide funds for stocking of devices and other resources for family planning services.

State teams may benefit from facility development of informed consent protocols on inpatient LARC insertion. State teams acknowledged that facilities should train providers on applying ethical and client-centered contraceptive counseling on all contraceptive method options, following ACOG guidance for informed consent.⁶⁰ Many state teams recognized a need to strengthen resources on informed consent and confidentiality for inpatient LARC insertion by focusing on development of protocols that use a reproductive justice framework within the comprehensive contraceptive counseling process.³⁴

There are some limitations to the interpretation of these findings. First, these findings represent states that reported enacting activities across the eight domains. It is possible that more states are engaged in such activities, but did not describe these efforts in the interviews. Second, these data may not be generalizable to the entire United States, as we only interviewed the 13 states participating in the LC. Despite this limitation, we included states with varying degrees of resources, health department structures, at different stages of implementing immediate postpartum LARC policy, and from different geographic regions across the country. Third, we interviewed in a team setting, rather than individually with each team member. This method allowed for observation of group interaction, but may have influenced individual responses. Finally, we do not measure the impact of implementation strategies, as the LC was not designed to test differences among states that do and do not implement strategies.

Proctor et al. recommend implementation strategies be clear in description, operational definition, and measurement.³² Successful strategies result in improvement of feasibility, cost, penetrability, and sustainability.⁶¹ Although the LC was not designed to test implementation strategies, the LC evaluation attempts to define, operationalize, and justify each strategy within each domain. These results describe the benefits of using state-developed strategies to support immediate postpartum LARC policy implementation. The findings from this descriptive study suggest that leveraging partnerships is a cross-cutting strategy for advancing implementation efforts that increase access to immediate postpartum LARC. Results also provide examples of domains in which strategies were implemented to address barriers to immediate postpartum LARC uptake and areas of focus for future strategy development. Further research quantifying feasibility, adherence, and sustainability of strategies implemented may help support policy change.

The LC provided an environment for state teams to discuss strategies most often related to increasing provider training, outreach, payment streams and reimbursement, and data, monitoring, and evaluation. To ensure that all clients have access to confidential and ethical reproductive health services regardless of birthing facility location, more states may consider stocking devices in all types of facilities and strengthening informed consent protocols. Provider champions may serve to promote evidence-based client-centered contraceptive counseling, increase training and capacity of facilities based in rural and underserved areas, and promote on-site stocking of LARC in hospitals. Pilot testing of toolkits and protocols can inform scale-up of policies throughout a state, and measurement of program impact provides the data necessary to replicate and adapt a policy framework in diverse settings. Providing LARC immediately postpartum is a convenient and cost-effective strategy to optimize birth spacing and reduce unintended pregnancy for women who are actively engaged in the health care system; states may consider these identified strategies to facilitate policy implementation and increase access to contraception and preventive health services.