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

It has been recommended in national guidelines that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (LARC). Significant barriers exist for hospitals offering these services. Efforts to improve peripartum contraception care quality have achieved mixed success, highlighting the need for more effective implementation interventions. One promising approach to improving peripartum contraceptive care quality is the use of implementation toolkits-packages of resources supporting change in clinical practice, which may include tools informing institutional policy, training practitioners and staff, mapping workflow, and performance. Patient-centeredness, a core domain of health care quality, is a key outcome for contraceptive quality improvement efforts. A number of studies suggest that contraceptive care is affected by health care workers' biases, which sometimes results in failures to address patient-centeredness, patient needs, and preferences, and patients feel subtly or overtly pressured in their contraceptive decision-making. Although multiple entities have examined immediate postpartum LARC implementation toolkits, none have been rigorously evaluated for acceptability and effectiveness. The aim of this study was to develop a theory-informed toolkit, evaluate its feasibility and acceptability for patientcentered, immediate postpartum LARC services, and refine the toolkit for future effectiveness testing. The study was conducted at a large academic medical center between 2017 and 2020. Toolkit resources to be used in a multicomponent implementation intervention was selected by a stakeholder panel comprising providers (midwives, family physicians, obstetricians, resident physicians, nurses, pharmacy and billing staff, and trained patient advocates) to lead implementation efforts. Implementation process outcomes measured to guide toolkit refinements, included (1) provider and patient perceptions of implementation tools and the implementation process, and (2) health care quality outcomes, including institutional trends in prenatal contraceptive counseling rates, immediate postpartum LARC utilization rates, and patients' reported experience of contraceptive care. The implementation intervention was conducted from January 2018 to April 2019. Study outcomes included (1) implementation outcomes (ie, provider and patient perceptions of the implementation process and implementation tools both assessed via online provider survey); (2) health care quality outcomes (ie, trends in prenatal contraceptive counseling and in utilization of immediate postpartum LARCs both ascertained by institutional administrative data); and (3) 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. The following lists the study outcomes and results: implementation process-of the 172/401 (43%) of eligible clinicians participating in surveys, over two thirds (70%) were "extremely" or "somewhat" satisfied with the implementation process; prenatal contraceptive counseling-of the 4960 patients undergoing childbirth, 1789 (36.1%) had documented evidence of 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 LARC utilization -across the study period, the overall proportion of patients using immediate postpartum LARC increased (preimplementation, 5.46% of deliveries; during implementation, 8.95%; postimplementation, 8.58%); patient experience of care-patient respondents were mostly White (344/425, 81%) and highly educated (309/425, 73% with at least a 4-year college degree), reflecting the population of the study site. The proportion of patients giving an "excellent" rating for all 4 items in the adapted Person-Centered Contraceptive Counseling measure was low in all settings from 2018 to 2020; there were lower scores in the hospital setting (prenatal visits, 67% to 63%; hospital, 45% to 58%; outpatient postpartum, 69% to 65%). Both provider and patient survey findings are limited by low response rates. Based on these findings, toolkit refinements were made: additional resources to routinize prenatal contraceptive counseling and to support a more patient-centered experience of contraceptive care. These findings suggest that a toolkit-based process to implement immediate postpartum LARC is feasible and acceptable. At a single academic center, toolkit postpartumLARC services achieved high acceptability, but mixed health care quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future studies should formally test effectiveness of the refined toolkit in a rigorous full powered multisite, prospective trial.