If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North CarolinaDepartment of Obstetrics and Gynecology, WakeMed Health and Hospitals, Raleigh, North Carolina
Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North CarolinaDepartment of Obstetrics and Gynecology, WakeMed Health and Hospitals, Raleigh, North Carolina
To assess why postpartum women who desired long-acting reversible contraception (LARC) did not receive it in the postpartum period and to assess which contraceptive methods they were using instead.
Study Design
This was a subgroup analysis of 324 women enrolled in a randomized, controlled trial to receive or not receive an educational LARC script during their postpartum hospitalization. Participants in this subgroup analysis stated that they were either using LARC (n = 114) or interested in using LARC (n = 210) during a follow-up survey completed after their scheduled 6-week postpartum visit. Modified Poisson regression analysis was used to assess for characteristics associated with using LARC by the time of the follow-up survey.
Results
Women who were interested in LARC but not using it were more likely to be multiparous (relative risk [RR], 1.59; 95% CI, 1.19–2.11) and to have missed their postpartum visit (RR, 25.88; 95% CI, 3.75–178.44) compared with those using LARC. Among the interested 210 who were not using LARC, the most common reasons provided for non-use were that they were told to come back for another insertion visit (45%), missed the postpartum visit (26%), and could not afford LARC (11%). The most common contraceptive methods used instead of LARC were barrier methods (42%) and abstinence (19%); 18% used no contraceptive method.
Conclusion
Two-thirds (65%) of postpartum women who desired to use LARC did not receive it in the postpartum period and used less effective contraceptive methods. Increasing access to immediate postpartum LARC and eliminating two-visit protocols for LARC insertion may increase postpartum LARC use. As the Affordable Care Act moves toward full implementation, it is necessary to understand the barriers that prevent interested patients from receiving LARC.
The postpartum period is a unique time where women typically have consistent and frequent access to medical providers, have increased opportunity for insurance with contraceptive coverage, and are highly motivated to avoid a rapid, repeat pregnancy (
). The health risks of short pregnancy intervals, defined as an interval of less than 18 months between delivery and subsequent conception, are now accepted (
). Long-acting reversible contraception (LARC), which consists of intrauterine contraception and subdermal contraceptive implants, has been shown to decrease short interval pregnancy among high-risk populations (
Centers for Disease Control and Prevention. (2010). U.S. medical eligibility criteria for contraceptive use, 2010: Adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th edition. MMWR Recommended Reports. 59(RR-4), 1-86.
American College of Obstetricians and Gynecologists (ACOG) ACOG Committee Opinion #450, Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy.
American College of Obstetricians and Gynecologists,
Washington, DC2011
). Although unique domestic factors cause many low- and middle-income women to have limited or absent insurance to cover LARC, the Contraceptive Choice Project in St. Louis has demonstrated how elimination of three large systemic barriers (increased upfront costs, lack of patient knowledge, and inaccurate provider counseling) can dramatically increase LARC uptake, with high rates of user satisfaction and decreased unintended pregnancy rates (
). Colorado has experienced similar statewide reductions in births among teens, a 40% reduction, by offering more than 30,000 LARC devices at no cost to patients (
National and state patterns of teen births in the United States, 1940-2013.
National vital statistics reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.2014; 63: 1-34
The challenge, therefore, is to increase uptake for this captive, medically engaged, and fertile cohort. Identifying the challenges to delivering LARC to this population is critical. The objective of this article was to analyze self-reported barriers to LARC among a cohort of postpartum women who reported a desire for LARC, but who did not receive their desired choice of contraception. Additionally, we assessed which characteristics were associated with receiving LARC among women who were interested in using it.
Materials and Methods
We conducted a subgroup analysis of data from a randomized, controlled trial (RCT) comparing use of a postpartum educational script on subsequent contraceptive uptake. The methodology and results of this RCT have been published previously (
). The main outcome of the primary study was to determine if receiving an evidence-based LARC script in the immediate postpartum period would increase postpartum LARC use. Immediate postpartum women were recruited from an urban, private, not-for-profit hospital in Raleigh, North Carolina, and study data were collected from May 2011 through April 2012. Participants were randomized to either receive a 1-minute LARC script or standard postpartum contraceptive counseling before discharge from their postpartum hospitalization. Participants then completed two follow-up surveys, the second of which (follow-up survey 2) was administered after the woman had been scheduled to attend her 6-week postpartum visit. Follow-up survey 2 was a 25-question instrument that took approximately 10 minutes to complete.
Participants began receiving calls from the study the day after their scheduled 6-week postpartum visit. To minimize loss to follow-up, participants were contacted up to five times on telephone numbers or email addresses provided. If there was no response, the study contacted the participant's clinic and pediatric clinic (assuming the participant had granted permission during her enrollment). When all of these methods failed, the survey was sent to the woman by mail with a pre-stamped, addressed envelope. A participant was deemed “lost to follow-up” if the mailed survey was not returned within 1 month. The median number of days between completion of follow-up survey 2 and the scheduled date of the participant's 6-week postpartum visit was 11 days (range, 0–121). Participants were compensated with a $10 Walmart gift card that was mailed to them after completing follow-up survey 2.
Of the 800 randomized participants, 738 (92%) completed follow-up survey 2. Of these 738 women, 324 (44%) were interested in using LARC. “Interested” in LARC was defined by participants answering the following question: “Are you interested in using the intrauterine device (the IUD) or birth control implant (Implanon) for birth control?” with a follow-up question asking about specific interest in the IUD, implant, or both. Only 14% (114/738) of the sample that completed follow-up survey 2 were using LARC (Figure 1). Of the 114 women using LARC, 56 (49%) were using the implant, 57 (50%) were using an IUD (combination of both the Levonorgestrel IUS and the Copper IUD), and 1 (1%) was missing the response for type of LARC (
). Postpartum visits occurred at a combination of private obstetrician/gynecologist offices, the Wake County Health Department, and a high-risk clinic associated with WakeMed hospital, the site of recruitment. Of note, in North Carolina, women who have no insurance and are undocumented immigrants can only apply for emergency Medicaid for their delivery, which does not cover LARC. Women who have no insurance but are U.S. citizens or with eligible immigration status could apply for LARC if they met state financial eligibility criteria for Medicaid for Pregnant Women or the Family Planning Waiver.
Figure 1Flow diagram describing the cohort that responded to follow-up survey 2.
The primary purpose of this subgroup analysis was to describe the self-reported barriers that prevented participants interested in but not using LARC from receiving their desired method. Of note, the hospital where the research took place lacked a reimbursement mechanism for placement of LARC during the postpartum hospitalization, so participants did not routinely receive LARC before their 6-week postpartum visit. The RCT received approval from the Institutional Review Boards of the University of North Carolina and WakeMed Health and Hospitals.
Descriptive statistics were used to summarize baseline variables within the cohort. Reasons for not using LARC were then examined by preferred LARC method. For those interested in but not using LARC, current contraceptive method was also examined. Multivariable modified Poisson regression analysis was used to estimate the unadjusted and adjusted relative risks (RRs) and 95% CIs for characteristics potentially associated with obtaining LARC. We identified eight characteristics that we hypothesized might be associated with the outcome of obtaining LARC (Table 1). We removed characteristics from the model if they were found to be collinear with other characteristics (a variance inflation factor of >2.5) or to have a p value greater than .250 in the unadjusted analysis. We used Wald χ2 square tests to assess the significance of the association between each of the characteristics in the final model and the outcome of obtaining LARC. All statistical tests were performed using STATA 11.0 (STATA Corporation, College Station, TX).
Table 1Unadjusted and Adjusted RRs for Women Who Were Interested in LARC and Received It
Characteristic
Interested in LARC But Did Not Receive It (n = 210), n (%)
Interested in LARC and Received It (n = 114), n (%)
Calculated using modified Poisson regression model and Wald χ2 test, adjusting for parity, insurance, attendance of ≥1 postpartum visit, and breastfeeding.
Calculated using modified Poisson regression model and Wald χ2 test, adjusting for parity, insurance, attendance of ≥1 postpartum visit, and breastfeeding.
Age (y)
<.001
N/A
N/A
14–17
5 (2)
11 (10)
2.03 (1.40, 2.94)
18–34
182 (87)
93 (81)
Reference
≥35
23 (11)
10 (9)
0.90 (0.52, 1.54)
Parity
<.001
<.001
Primiparous
54 (26)
53 (46)
1.76 (1.32, 2.35)
1.59 (1.19, 2.11)
Multiparous
156 (74)
61 (54)
Reference
Reference
Pregnancy intention/using contraception at time of conception
† Calculated using modified Poisson regression mode.
‡ Calculated using modified Poisson regression model and Wald χ2 test, adjusting for parity, insurance, attendance of ≥1 postpartum visit, and breastfeeding.
This subgroup analysis describes the barriers for the 210 women who were interested in, but did not receive a LARC by the time of follow-up survey 2 (Figure 1). Among these women, 75% were interested in an IUD, 20% were interested in the implant, 3% were interested in both, and 2% were not sure as to which method they desired. Of note, 144 of the 210 women (69%) who were interested in but not using LARC had attended at least one postpartum visit; 77% of those interested in an IUD had attended at least one postpartum visit compared with 56% of those interested in the implant.
The majority of women were 18 to 34 years old, self-reported Hispanic, and had no insurance and thus were self-pay (Table 1). Seventy-four percent of the sample was multiparous, and 91% reported that they did not desire another pregnancy within 2 years. Table 1 also includes the characteristics of 114 women in the study who received LARC by the time of follow-up survey 2. In unadjusted analysis, women who received LARC were more likely to be younger, primiparous, non-Hispanic, and to have insurance. Age and race/ethnicity were dropped from the final model because they were found to be collinear with parity and insurance, respectively. Adjusted analyses revealed that being primiparous (RR, 1.59; 95% CI, 1.19–2.11) and having attended at least one postpartum visit (RR, 25.88; 95% CI, 3.75–178.44) were still significantly associated with receiving LARC (Table 1).
Common reasons for not receiving the intended LARC method included being told to return for an additional visit for insertion and a missed 6-week postpartum visit (Table 2). Four percent of those interested in the IUD did not receive it because their clinician required additional laboratory or diagnostic testing (none of those interested in the implant reported this restriction). Fifteen percent of those desiring an implant reported that the clinic did not have their desired method; it is important to note that one of the clinics that was attended by 94 (45%) of our participants ran out of implants for a period of 6 months because of a budget shortfall. Forty-nine percent (77/158) of the women interested in an IUD and 29% (12/41) of the women interested in the implant reported that they had scheduled a future insertion visit; however, we do not have data on whether these women attended this visit or received their preferred LARC method then.
Table 2Reasons for Not Using LARC and Past and Future Postpartum Visits
American College of Obstetricians and Gynecologists (ACOG) ACOG Committee Opinion #450, Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy.
American College of Obstetricians and Gynecologists,
Washington, DC2011
), with another 40% reporting abstinence, withdrawal or no contraceptive method (Table 3). Only 21% were using hormonal methods or lactational amenorrhea, which are considered more effective than barrier methods (
American College of Obstetricians and Gynecologists (ACOG) ACOG Committee Opinion #450, Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy.
American College of Obstetricians and Gynecologists,
Washington, DC2011
In our population of postpartum women in North Carolina, only one-third of women who desired a LARC received it at their standard 6-week postpartum visit. Women who did not receive these most effective forms of contraception were relying on less effective methods and therefore were at increased risk for rapid, repeat pregnancy. These women were also more likely to be multiparous and to have missed their postpartum visit compared with women who received LARC during the study period. Requirement for an additional LARC insertion visit, missed postpartum visits, and financial reasons were the most commons reasons cited for not receiving LARC, and these women were relying on barrier methods, abstinence, or no method. Furthermore, additional systemic, but largely modifiable, barriers to LARC were noted, including being out of stock and restrictive testing requirements.
Postpartum women, especially high-risk groups including adolescents, who do not receive LARC immediately postpartum have a significantly increased risk of repeat pregnancy (
). Clinic practices that result in an increase in same-day access to LARC among postpartum women decrease unintended pregnancy rates. One important quality improvement outcome of the larger RCT is that the postpartum clinic attended by the majority of our study population has revised its practices to eliminate the obstacles preventing same-day LARC insertion, which is supported by recommendations from the American College of Obstetricians and Gynecologists (
American College of Obstetricians and Gynecologists (ACOG) ACOG Committee Opinion #450, Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy.
American College of Obstetricians and Gynecologists,
Washington, DC2011
The barriers to LARC that we identified (requirements for additional visits, missed appointments, not having the LARC of choice available, and financial constraints) are similar to those reported by others (
). In a recent review of barriers for adolescents interested in LARC, reported mean out-of-pocket expenses for those without insurance for a LARC device and insertion exceeded $1,000 (
). Another analysis found that in patients with insurance coverage, the amount of copays can profoundly decrease rates of obtaining an IUD, because those with copays that exceeded $50 were 11 times less likely to obtain an IUD (
). The Contraceptive Choice Project, although not focused on a postpartum population, has achieved greater than 75% LARC usage rates by eliminating nearly every barrier mentioned by participants in this study (
). Interestingly, among this present postpartum cohort, the proportion of women who reported financial limitations as the primary barrier for LARC was less for the implant (7%) compared with the IUD (12%), a finding that has not been described in other studies.
Interventions to overcome barriers to postpartum LARC have been attempted with varying success (
). None of these studies included interventions that would eliminate specifically the most common barriers encountered in our subgroup analysis. One of the most successful of those studies for increasing long-term uptake of postpartum LARC involved an intensive program for adolescents which offered immediate postpartum implant insertion before the postpartum hospitalization discharge (
). Participants from our study in North Carolina did not have access to immediate postpartum LARC. Another recent RCT attempted to overcome common clinic barriers to LARC by allocating postpartum women to receiving a personal assistant to facilitate contraception compared with standard care, and the study concluded that the personal assistant did not increase LARC uptake (
). The study found that key barriers to LARC initiation included inaccurate provider counseling, financial limitation, and challenges with postpartum clinic visits and scheduling. In their review of the background literature, 40% to 75% of women desiring postpartum LARC ultimately do not receive their intended device, similar to rates seen in this current analysis. Within our primary RCT, interest in LARC was only 43%, and the educational intervention of the LARC script statistically increased interest in, but not uptake of, LARC (
) uncovered some similar structural barriers to those described in our analysis (provider counseled against LARC and financial barriers); however, the study in New Mexico relied on a review of medical records, whereas our results are from direct patient questioning.
One opportunity to eliminate nearly all of the identified barriers from this analysis is immediate postpartum LARC insertion, where LARC is placed before discharge from the delivery hospitalization. With immediate postpartum LARC insertion, IUDs are typically placed within 10 minutes of placental delivery, and implants are usually placed on the day of discharge (
). Although immediate postpartum LARC placement offers numerous benefits, the financial, logistical, and training challenges have profoundly limited broad implementation. The largest current challenge is the lack of standard funding mechanisms to reimburse LARC device and insertion during the delivery hospitalization (
). Women in this current study were not offered immediate postpartum routinely LARC owing to these funding restraints. Even if the challenges to immediate postpartum LARC are overcome, some women still may not desire LARC in the immediate postpartum period owing to concerns regarding lactation, discomfort of the procedure, or other factors. Therefore, it is critical to ensure that LARC insertion can occur without barriers at any time in the postpartum period when insertion is evidence based. This subgroup analysis also highlights how other barriers specific to the postpartum clinic, including stocking of LARC devices, interruptions of state funding for LARC devices, and pre-placement policies can also prevent efficient and evidence-based practices that facilitate LARC placement in a single postpartum visit. Finally, it is critical to understand region-specific barriers preventing widespread postpartum LARC uptake, because barriers among this cohort in North Carolina may be different than in other geographical areas.
Strengths of this analysis include the large number of postpartum women with a high follow-up rate from the larger RCT. The population included in this sample represents a highly diverse, urban cohort with the majority of participants identifying as women of color and lacking private insurance. Women in this subgroup analysis were more likely to be Hispanic and self-pay compared with the larger, RCT cohort. Weaknesses of this study includes that the LARC barriers described are self-reported without validation by the clinic or claims data. Additionally, a substantial number of women may have received LARC devices at subsequent visits after the study window.
Implications for Practice and/or Policy
Elimination of barriers that prevent women interested in LARC from receiving their desired contraception has the potential to increase postpartum uptake of LARC. Increasing uptake of LARC has important public health implications, such as an increase in interpregnancy intervals, a decrease in unplanned pregnancy, and a decrease in abortion. High upfront costs, supply limitations, and non–evidence-based requirements that prevent same-day or immediate postpartum LARC insertion should be eliminated. As the Affordable Care Act progresses through subsequent steps of implementation, policymakers should continue to minimize financial and logistical barriers to LARC for reproductive age women, especially those in the postpartum period with interest in LARC.
Acknowledgments
The authors thank the study participants, WakeMed Health and Hospitals, Wake County Human Services, Karen Dorman, Kathia Peña-Centeno, Erika Campos, Sandra Re, Bryna Waters, Sarah Melvin, Rosalie Dominik, and Bill Miller.
References
Ali M.
Seuc A.
Rahimi A.
Festin M.
Temmerman M.
A global research agenda for family planning: Results of an exercise for setting research priorities.
Bulletin of the World Health Organization.2014; 92: 93-98
Centers for Disease Control and Prevention. (2010). U.S. medical eligibility criteria for contraceptive use, 2010: Adapted from the World Health Organization medical eligibility criteria for contraceptive use, 4th edition. MMWR Recommended Reports. 59(RR-4), 1-86.
National and state patterns of teen births in the United States, 1940-2013.
National vital statistics reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.2014; 63: 1-34
Matthew L. Zerden, MD, MPH, recently completed his fellowship in Family Planning at the University of North Carolina. He is currently an OB/GYN hospitalist at WakeMed North Family Health & Women's Hospital. His research interests include postpartum contraception, integrating maternal and infant health service delivery, and surgical sterilization.
Jennifer H. Tang, MD, MSCR, is Assistant Professor at the University of North Carolina (UNC). She is based currently at the UNC Project-Malawi in Lilongwe. Her research focuses on international family planning (HIV and contraception, postpartum family planning), obstetric fistula, and maternal health.
Gretchen S. Stuart, MD, MPHTM, is an Associate Professor and the Division Director of Family Planning in the Department of Obstetrics and Gynecology at the University of North Carolina. Her areas of research include postpartum contraception, genital tract infections, and HIV/AIDS and contraception.
Deborah R. Norton, MD, MPH, is a family and preventive medicine physician working for Wake County Human Services - Women's Health Clinic in Raleigh, North Carolina. Her research interests include postpartum care and increasing access to contraception and cervical cancer screening.
Sarah B. Verbiest, DrPH, MSW, MPH, is Executive Director of the UNC Center for Maternal & Infant Health, and Assistant Professor at the School of Medicine. Her research interests include preterm birth prevention; preconception health; postpartum care; and smoking cessation in pregnant and new mothers.
Seth Brody, MD, MPH, is the Executive Medical Director of the Women's Hospital at WakeMed North and a Clinical Professor at the UNC School of Medicine. His research interests include hospital quality improvement, postpartum contraception, and gestational diabetes.
Article info
Publication history
Published online: July 23, 2015
Accepted:
June 10,
2015
Received in revised form:
June 9,
2015
Received:
January 15,
2015
Footnotes
Disclosure statement: The authors report no conflicts of interest.
Source of financial support: This study was funded by the Society of Family Planning. The Society of Family Planning did not have any direct role in study design, data collection, analysis or interpretation of the findings.
00092-4&id=gr1.jpg){kind=link}