Medicaid and Fulfillment of Postpartum Permanent Contraception Requests

Arora, Kavita Shah; Chua, Arzice; Boozer, Margaret; Serna, Tania; Bullington, Brooke W.; White, Kari; Gunzler, Douglas D.; Bailit, Jennifer L.; Berg, Kristen A.

doi:10.1097/aog.0000000000005130

Cited by 9 publications

(21 citation statements)

References 30 publications

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“…However, the primary analysis from this cohort study revealed that cesarean delivery was the factor most strongly associated with fulfillment of postpartum permanent contraception. 12 Thus, the racial and ethnic differences in delivery type may interact with hospital-level barriers to permanent contraception among individuals who delivery vaginally, potentially Our findings thus reinforce the limitations of how race and ethnicity are often used in the scientific literature. When modeling associations between race, as a proxy for racism, and health outcomes, we often account for biological covariates such as age and parity.…”

Section: Discussionsupporting

confidence: 52%

“…Multiple studies suggest that people with Medicaid insurance are less likely to have their desired postpartum permanent contraception procedure fulfilled. [6][7][8][9][10][11][12] As a result of structural racism and discrimination, Black and Hispanic people are more likely to have Medicaid insurance and therefore are more likely to face this policy as a barrier. 13 A study using longitudinal National Survey of Family Growth data from 2006 to 2010 reported that privately insured Black and Hispanic people were more likely to undergo permanent contraception compared with privately insured White people.…”

Section: Discussionmentioning

confidence: 99%

“…The primary report from these analyses contains further methodologic details. 12 Our primary outcomes were fulfillment of postpartum permanent contraception at three time points after delivery, operationalized as dichotomous variables: before hospital discharge, within 6 weeks of delivery, and within 365 days of delivery. Within 6 weeks of delivery was chosen because it is the clinical end of the postpartum period and is the time frame at which Medicaid expires in many states.…”

Section: Methodsmentioning

confidence: 99%

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Association Among Race, Ethnicity, Insurance Type, and Postpartum Permanent Contraception Fulfillment

Bullington,

Berg,

Miller

et al. 2023

Obstetrics &Amp; Gynecology

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OBJECTIVE: To evaluate the association among race, ethnicity, insurance type, and fulfillment of permanent contraception requests. METHODS: This is a secondary analysis of a retrospective cohort of patients who delivered at 20 or more gestational weeks in a 2-year time period at four hospitals across the United States: University of California San Francisco, Northwestern Memorial Hospital, MetroHealth Medical Center in Cleveland, and University of Alabama at Birmingham. All patients included had permanent contraception documented as their postpartum contraceptive plan. We used modified Poisson models to estimate the associations among race and ethnicity, insurance type, and fulfillment of permanent contraception before hospital discharge, within 6 weeks of delivery, and within 1 year of delivery, adjusting for age, parity, gestational age, delivery type, marital status, body mass index, insurance type, adequacy of prenatal care, and hospital site. RESULTS: Of 2,945 people in our cohort, 1,243 (42.2%) were non-Hispanic Black, and 820 (27.8%) were Hispanic, and 882 (30.0%) were non-Hispanic White. Overall, 1,731 of 2,945 patients (58.2%) who desired postpartum permanent contraception received it before hospital discharge, 1,746 of 2,945 (59.3%) received it within 6 weeks of delivery, and 1,927 of 2,945 (65.4%) received it within 1 year of delivery. Across all racial and ethnic groups, patients with Medicaid insurance were less likely to have their desired postpartum permanent contraception procedure fulfilled compared with patients with private insurance. In unadjusted models, non-Hispanic Black patients were less likely to have their desired postpartum permanent contraception procedure fulfilled. In an examination of interaction with insurance type, non-Hispanic Black patients with private insurance were less likely to have permanent contraception fulfilled compared with non-Hispanic White patients with private insurance before adjustment. After adjustment, there were no significant associations between race and postpartum permanent contraception fulfillment among those with Medicaid or private insurance. CONCLUSION: In unadjusted models, we find marked racial disparities in fulfillment of permanent contraception. Controlling for individual- and facility-level factors eliminated associations among race, ethnicity, insurance type, and fulfillment, likely because covariates are mediators on the pathway between racism and fulfillment.

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Section: Discussionsupporting

confidence: 52%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Association Among Race, Ethnicity, Insurance Type, and Postpartum Permanent Contraception Fulfillment

Bullington,

Berg,

Miller

et al. 2023

Obstetrics &Amp; Gynecology

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“…There are corrections to Arora et al 1 in the May 2023 issue. As the authors conducted secondary analyses of the data set, they discovered that 10 patients were miscoded in fulfillment of permanent contraception by 365 days (but were correctly classified at their endpoints by hospital discharge and 42 days postpartum).…”

mentioning

confidence: 99%

“…5 in the April 2023 issue is incorrect. 1 The correct title is, "Improving Access to Intrauterine Devices and Contraceptive Implants." In addition, the title in the citation at the end of the article on page 872 contains the incorrect title.…”

mentioning

confidence: 99%

Medicaid and Fulfillment of Postpartum Permanent Contraception Requests: Correction

2023

Obstetrics &Amp; Gynecology

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Neighbourhood socioeconomic position, prenatal care and fulfilment of postpartum permanent contraception: Findings from a multisite cohort study

Berg,

Bullington,

Gunzler

et al. 2023

Repro Female Child Health

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IntroductionResearch suggests neighbourhood socioeconomic vulnerability is negatively associated with women's likelihood of receiving adequate prenatal care and achieving desired postpartum permanent contraception. Receiving adequate prenatal care is linked to a greater likelihood of achieving desired permanent contraception, and access to such care may be critical for women with Medicaid insurance given that the federally mandated Medicaid sterilization consent form must be signed at least 30 days before the procedure. We examined whether adequacy of prenatal care mediates the relationship between neighbourhood socioeconomic position and postpartum permanent contraception fulfilment, and examined moderation of relationships by insurance type.MethodsThis secondary analysis of a retrospective cohort study examined 3012 Medicaid or privately insured individuals whose contraceptive plan at postpartum discharge was permanent contraception. Path analysis estimated relationships between neighbourhood socioeconomic position (economic hardship and inequality, financial strength and educational attainment) and permanent contraception fulfilment by hospital discharge, directly and indirectly through adequacy of prenatal care. Multigroup testing examined moderation by insurance type.ResultsAfter adjusting for age, parity, weeks of gestation at delivery, mode of delivery, race, ethnicity, marital status and body mass index, having adequate prenatal care predicted achieving desired sterilization at discharge (β = 0.065, 95% confidence interval [CI]: 0.011, 0.117). Living in neighbourhoods with less economic hardship (indirect effect −0.007, 95% CI: −0.015, −0.001), less financial strength (indirect effect −0.016, 95% CI: −0.030, −0.002) and greater educational attainment (indirect effect 0.012, 95% CI: 0.002, 0.023) predicted adequate prenatal care, in turn predicting achievement of permanent contraception by discharge. Insurance status conditioned some of these relationships.ConclusionContact with the healthcare system via prenatal care may be a mechanism by which neighbourhood socioeconomic disadvantage affects permanent contraception fulfilment, particularly for patients with Medicaid. To promote reproductive autonomy and healthcare equity, future inquiry and policy might closely examine how neighbourhood social and economic characteristics interact with Medicaid mandates.

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Medicaid and Fulfillment of Postpartum Permanent Contraception Requests

Abstract: Analysis of a multisite cohort reveals that efforts are needed to ensure that patients with Medicaid insurance who desire permanent contraception receive timely and equitable care.

Cited by 9 publications

References 30 publications

Association Among Race, Ethnicity, Insurance Type, and Postpartum Permanent Contraception Fulfillment

Association Among Race, Ethnicity, Insurance Type, and Postpartum Permanent Contraception Fulfillment

Medicaid and Fulfillment of Postpartum Permanent Contraception Requests: Correction

Neighbourhood socioeconomic position, prenatal care and fulfilment of postpartum permanent contraception: Findings from a multisite cohort study

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