Contraception After Delivery Among Publicly Insured Women in Texas

Abstract

Objective To assess women’s preferences for contraception after delivery, and to compare use with preferences. Methods In a prospective cohort study of women aged 18–44 years who wanted to delay childbearing for at least 2 years, we interviewed 1,700 participants from eight hospitals in Texas immediately postpartum and at 3 and 6 months after delivery. At 3 months, we assessed contraceptive preferences by asking what method women would like to be using at 6 months. We modeled preference for highly effective contraception and use given preference according to childbearing intentions using mixed-effects logistic regression, testing for variability across hospitals and differences between those with and without immediate postpartum long-acting reversible contraception (LARC) provision. Results Approximately 80% completed both the 3 and 6-month interviews (1367/1700). Overall, preferences exceeded use for both LARC: 40.8% [n=547] vs. 21.9% [n=293] and sterilization: 36.1% [n=484] vs. 17.5% [n=235]. In the mixed-effects logistic regression models, several demographic variables were associated with a preference for LARC among women who wanted more children, but there was no significant variability across hospitals. For women who wanted more children and had a LARC preference, use of LARC was higher in the hospital that offered immediate postpartum provision (p<0.035), as it was for US-born women (OR 2.08, 95% CI 1.17–3.69) and women with public prenatal care providers (OR 2.04, 95% CI 1.13–3.69). In the models for those who wanted no more children, there was no significant variability in preferences for long-acting or permanent methods across hospitals. However, use given preference varied across hospitals (P<0.001) and was lower for Black women (OR 0.26, 95% CI 0.12–0.55), and higher for US-born women (OR 2.32, 95% CI 1.36–3.96), those over 30 (OR 1.82, 95% CI 1.07–3.09), and those with public prenatal care providers (OR 2.04, 95% CI 1.18–3.51). Conclusion Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of provider and system-level barriers. Expansion of immediate postpartum LARC provision as well as contraceptive coverage for undocumented women could reduce the gap between preference and use.

Low‐Income Texas Women's Experiences Accessing Their Desired Contraceptive Method at the First Postpartum Visit

“…Requiring women to return to the clinic for financial screening on a different day often led to other barriers. Foreign‐born Hispanic women were more likely than U.S.‐born Hispanic women to experience a cost barrier, and previous research found that foreign‐born individuals were less likely than U.S.‐born ones to be relying on their desired IUD, implant or sterilization at six months postpartum . Thus, expanding public insurance coverage to immigrants, regardless of documentation status, as well as providing same‐day appointments for financial screening, could improve access to postpartum contraception.…”

Challenging unintended pregnancy as an indicator of reproductive autonomy

“…wanted to be using a highly effective method at 6 months postpartum compared to 39% actually using one [31]. Among Texas community college students, 21% wanted to be using an IUD or implant, but less than half (9%) were [32].…”

Contraception after pregnancy

“…Even in high‐income countries, provision of effective contraception after delivery is often sub‐optimal. Only around 50% of postpartum women in a Texan study expressing a preference for either long‐acting reversible contraception (LARC) or sterilization received their preferred method . About 70% of pregnancies occurring within 1 year postpartum in the USA are unintended .…”