Abstract
Introduction
In the last decade, state and national programs and policies aimed to increase access
to postpartum contraception; however, recent data on population-based estimates of
postpartum contraception is limited.
Methods
Using Pregnancy Risk Assessment Monitoring System data from 20 sites, we conducted
multivariable-adjusted weighted multinomial regression to assess variation in method
use by insurance status and geographic setting (urban/rural) among people with a recent
live birth in 2018. We analyzed trends in contraceptive method use from 2015 to 2018
overall and within subgroups using weighted multinomial logistic regression.
Results
In 2018, those without insurance had lower odds of using permanent methods (adjusted
odds ratio [AOR], 0.72; 95% confidence interval [CI], 0.53–0.98), long-acting reversible
contraception (LARC) (AOR, 0.67; 95% CI, 0.51–0.89), and short-acting reversible contraception
(SARC) (AOR, 0.61; 95% CI, 0.47–0.81) than those with private insurance. There were
no significant differences in these method categories between public and private insurance.
Rural respondents had greater odds than urban respondents of using all method categories:
permanent (AOR, 2.15; 95% CI, 1.67–2.77), LARC (AOR, 1.31; 95% CI, 1.04–1.65), SARC
(AOR, 1.42; 95% CI, 1.15–1.76), and less effective methods (AOR, 1.38; 95% CI, 1.11–1.72).
From 2015 to 2018, there was an increase in LARC use (odds ratio [OR], 1.03; 95% CI,
1.01–1.05) and use of no method (OR, 1.05; 95% CI, 1.02–1.07) and a decrease in SARC
use (OR, 0.97; 95% CI, 0.95–0.99). LARC use increased among those with private insurance
(OR, 1.05; 95% CI, 1.02–1.08) and in urban settings (OR, 1.04; 95% CI, 1.02–1.07),
but not in other subgroups.
Conclusions
We found that those without insurance had lower odds of using effective contraception
and that LARC use increased among those who had private insurance and lived in urban
areas. Strategies to increase access to contraception, including increasing insurance
coverage and investigating whether effectiveness of existing initiatives varies by
geographic setting, may increase postpartum contraceptive use and address these differences.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Women's Health IssuesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: An updated systematic review.Pediatric and Perinatal Epidemiology. 2019; 33: O25-O47
- Global fee prohibits postpartum provision of the most effective reversible contraceptives.Contraception. 2015; 90: 466-467
- About us.(Available:)
- Committee opinion no. 666: Optimizing postpartum care.Obstetrics and Gynecology. 2016; 127: e187
American Rescue Plan Act of 2021, Pub. L 117-2, 135 Stat. 212, § 9812 (March 11, 2021).
- Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: A analysis of insurance benefit inquiries.Contraception. 2016; 93: 139-144
- Women saw large decrease in out-of-pocket spending for contraceptives after ACA mandate removed cost sharing.Health Affairs. 2015; 34: 1204-1211
- Did increasing use of highly effective contraception contribute to declining abortions in Iowa?.Contraception. 2015; 91: 167-173
- Race, insurance status and tubal sterilization.Obstetrics & Gynecology. 2007; 109: 94-100
- Medicaid and CHIP eligibility, enrollment, and cost sharing policies as of January 2020: Findings from a 50-state survey.Henry J. Kaiser Family Foundation, San Francisco2020
- Variation in postpartum use of most and moderately effective contraceptive methods among Louisiana women.Maternal and Child Health Journal. 2020; 24: 1151-1160
- Affordable Care Act’s mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage.Health Affairs. 2016; 35: 1608-1615
- Implementation guide: Medicaid State Plan Eligibility.(Available:)
- RE: Improving maternal health and extending postpartum coverage in Medicaid and the Children’s Health Insurance Program (CHIP).Department of Health and Human Services, Baltimore, MD2021
- Contraception in Medicaid: Improving Maternal and Infant Health.(Available:)
- Women’s awareness of their contraceptive benefits under the Patient Protection and Affordable Care Act.American Journal of Public Health. 2015; 105: S713-S715
- Twelve-month contraceptive continuation and repeat pregnancy among young mothers choosing postdelivery contraceptive implants or postplacental intrauterine devices.Contraception. 2016; 93: 178-183
- Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.JAMA. 2006; 295: 1809-1823
- Social desirability and self-reported health risk behaviors in web-based research: Three longitudinal studies.BMC Public Health. 2010; 10: 720
- The association of health insurance with use of prescription contraceptives.Perspectives on Sexual and Reproductive Health. 2007; 39: 226-230
- U.S. selected practice recommendations for contraceptive use, 2016.Morbidity and Mortality Weekly Report. 2016; 65: 1-66
- U.S. Medical eligibility criteria for contraceptive use, 2016.Morbidity and Mortality Weekly Report. 2016; 65: 1-103
- Postpartum contraceptive use by urban/rural status: an analysis of the Michigan Pregnancy Risk Assessment Monitoring System (PRAMS) data.Contraception. 2013; 25: 622-627
- Current contraceptive use and variation by selected characteristics among women aged 15–44: United States, 2011–2013.National Center for Health Statistics, Hyattsville, MD2015
- Evaluation of Medicaid Expansion under the Affordable Care Act and contraceptive care in US community health centers.JAMA Network Open. 2020; 3: e206874
- Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage.American Journal of Obstetrics and Gynecology. 2014; 210: 311.e1-311.e8
- What is PRAMS?.(Available:)https://www.cdc.gov/prams/index.htmDate accessed: January 27, 2021
- Postpartum Medicaid coverage and contraceptive use before and after Ohio’s Medicaid expansion under the Affordable Care Act.Women’s Health Issues. 2020; 30: 426-435
- Improving access to contraception in Delaware.Delaware Journal of Public Health. 2018; 4: 6-10
- Changes in out-of-pocket payments for contraception by privately insured women during implementation of the federal contraceptive coverage requirement.Contraception. 2014; 89: 97-102
- Advancing person-centered LARC access among the Medicaid population. Institute for Medicaid Innovation.(Available:)www.medicaidinnovation.org/_images/content/2020-IMI-Advancing_Person-Centered_LARC_Access_in_Medicaid-Report.pdfDate: 2020Date accessed: February 1, 2022
- Providing quality family planning services: recommendations of CDC and the US Office of Population Affairs.Morbidity and Mortality Weekly Report. 2014; 63: 1-54
- Comparisons of contraceptive use between rural and urban teens.Journal of Pediatric and Adolescent Gynecology. 2016; 29: 33-41
- Contraceptive services after Medicaid expansion in a state with a Medicaid family planning waiver program.Journal of Women's Health. 2021; 30: 750-757
- Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods.Perspectives in Sexual and Reproductive Health. 2014; 46: 171-175
- Realizing reproductive health equity needs more than long-acting reversible contraception (LARC).American Journal of Public Health. 2016; 106: 18
- Closing Gaps in maternal health coverage: Assessing the potential of a postpartum Medicaid/CHIP extension. The Commonwealth Fund.(Available:)https://www.commonwealthfund.org/publications/issue-briefs/2021/jan/closing-gaps-maternal-health-postpartum-medicaid-chipDate: 2021Date accessed: February 1, 2022
- Women’s preventive services guidelines.(Available:)
- Provider bias in long-acting reversible contraception (LARC) promotion and removal: Perceptions of young adult women.American Journal of Public Health. 2016; 106: 1932-1937
- Implementing immediate postpartum long-acting reversible contraception programs.Obstetrics and Gynecology. 2018; 129: 3-9
- Accounting for missing data in statistical analyses: Multiple imputation is not always the answer.International Journal of Epidemiology. 2019; 48: 1294-1304
- Health insurance coverage and contraceptive use at the state level: findings from the 2017 Behavioral Risk Factor Surveillance System.Contraception: X. 2019; 2: 100014
- State-identified implementation strategies to increase uptake of immediate postpartum long-acting reversible contraception policies.Journal of Women's Health. 2019; 28: 346-356
- Meeting summary: State and local implementation strategies for increasing access to contraception during Zika preparedness and response — United States, September 2016.Morbidity and Mortality Weekly Report. 2017; 66: 1230-1235
- Working with state health departments on emerging issues in maternal and child health: Immediate postpartum long-acting reversible contraceptives.Journal of Women's Health. 2015; 24: 693-701
- Final program data and factors associated with long-acting reversible contraception removal.Obstetrics and Gynecology. 2020; 135: 1095-1103
- The Zika Contraception Access Network: A feasibility programme to increase access to contraception in Puerto Rico during the 2016–17 Zika virus outbreak.Public Health. 2018; 3: e91-e99
- Are women benefiting from the Affordable Care Act? A real-world evaluation of the impact of the Affordable Care Act on out-of-pocket costs for contraceptives.Contraception. 2016; 93: 392-397
- The influence of interpregnancy interval on infant mortality.American Journal of Obstetrics and Gynecology. 2017; 216: 316.e1-316.e9
- The Contraceptive CHOICE Project Round Up: What we did and what we learned.Clinical Obstetrics and Gynecology. 2014; 57: 635-643
- Characterization of Medicaid policy for immediate postpartum contraception.Contraception. 2015; 92: 523-531
- Association of access to family planning services with Medicaid expansion among female enrollees in Michigan.JAMA Network Open. 2018; 1: e181627
- NCHS Urban-Rural Classification Scheme for Counties.(Available:)https://www.cdc.gov/nchs/data_access/urban_rural.htmDate accessed: June 1, 2017
- Rural Health. Centers for Disease Control and Prevention.(Available:)https://www.cdc.gov/chronicdisease/resources/publications/factsheets/rural-health.htmDate: 2019Date accessed: July 3, 2022
- Strategies to increase access to long-acting reversible contraception (LARC) in Medicaid.(Available:)https://www.nichq.org/sites/default/files/resource-file/Increasing-Access-To-LARC_CoIIN-NASHP.pdfDate: 2016Date accessed: February 1, 2022
- Health insurance coverage and prescription contraceptive use among young women at risk for unintended pregnancy.Contraception. 2009; 79: 105-110
- Factors associated with postpartum use of long-acting reversible contraception.American Journal of Obstetrics and Gynecology. 2019; 221: 43.e1-43.e11
- Policy change is not enough: Engaging provider champions on immediate postpartum contraception.American Journal of Obstetrics and Gynecology. 2018; 218: 590.e1-590.e7
Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111 -148, 124 Stat. 119 (2010).
- Preventing unintended pregnancies by providing no-cost contraception.Obstetrics and Gynecology. 2014; 120: 1291-1297
- Publicly funded sites offering birth control by county.(Available:)https://powertodecide.org/system/files/resources/primary-download/Contraceptive%20Deserts_Handout.pdfDate accessed: February 1, 2022
- Postpartum coverage extension in the American Rescue Plan Act of 2021. Kaiser Family Foundation.(Available:)https://www.kff.org/policy-watch/postpartum-coverage-extension-in-the-american-rescue-plan-act-of-2021/Date: 2021Date accessed: February 1, 2022
- Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women.Perspectives on Sexual and Reproductive Health. 2014; 46: 125-132
- Disparities in Preconception Health Indicators — Behavioral Risk Factor Surveillance System, 2013–2015, and Pregnancy Risk Assessment Monitoring System, 2013–2014.Morbidity and Mortality Weekly Report. 2018; 67: 1-16
- Advocating for immediate postpartum LARC: increasing access, improving outcomes, and decreasing cost.Contraception. 2014; 90: 468-471
- The Contraceptive CHOICE Project: Reducing barriers to long-acting reversible contraception.American Journal of Obstetrics and Gynecology. 2010; 203: 115.e1-115.e7
- The Pregnancy Risk Assessment Monitoring System (PRAMS): Overview of design and methodology.American Journal of Public Health. 2018; 108: 1305-1313
- The impact of the Affordable Care Act on contraceptive use and costs among privately insured women.Women's Health Issues. 2018; 28: 219-223
Social Security Act, § 1902(e)(5); 42 USC § 1396a(e)(6).
- Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update.Contraception. 2015; 91: 44-48
- Postpartum contraception use by urban/rural status: An analysis of the Michigan Pregnancy Risk Assessment Monitoring System data.Women's Health Issues. 2015; 25: 622-627
- Intermittent Lack of Health Insurance Coverage and Use of Preventive Services.American Journal of Public Health. 2003; 93: 130-137
- Long-acting reversible contraception learning community year two in-person meeting report.(Available:)https://www.astho.org/Programs/Maternal-and-Child-Health/Documents/LARC-Immediate-Postpartum-Learning-Community-Full-Report/Date: 2015Date accessed: February 1, 2022
- ASTHO LARC learning community virtual learning session kick off call.(Available:)https://www.astho.org/Maternal-and-Child-Health/Long-Acting-Reversible-Contraception/LARC-Year-3-Kick-Off-Call/Slide-Deck/Date accessed: October 13, 2016
- Increasing access to contraception.(Available:)
- Urban-rural differences in tubal ligation incidence in the state of Georgia, USA.Journal of Rural Health. 2017; 34: 122-131
- Efficacy, safety, and personal considerations.in: Hatcher N.A. Contraceptive technology. 21st ed. Ayer Company Publishers, Inc, New York2018
- Women’s preventive services coverage and non-profit religious organizations.(Available:)https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/womens-preven-02012013Date accessed: February 1, 2022
- Birth control benefits.(Available:)www.healthcare.gov/coverage/birth-control-benefits/Date accessed: February 1, 2022
- HHS marks Black maternal health week by announcing measures to improve maternal health outcomes.(Available:)www.hhs.gov/about/news/2021/04/12/hhs-marks-black-maternal-health-week-announcing-measures-improve-maternal.htmlDate accessed: April 12, 2021
- Re: Medicaid family planning services and supplies.U.S. Centers for Medicare and Medicaid, Baltimore2016
- State Medicaid payment approaches to improve access to long-acting revirsible contraception.U.S. Centers for Medicare and Medicaid, Baltimore2016
- Variation in postpartum contraceptive method use: Results from the Pregnancy Risk Assessment Monitoring System (PRAMS).Contraception. 2013; 89: 57-62
Biography
Katharine Bruce, MPH, is a PhD student in Epidemiology at the University of North Carolina Gillings School of Public Health. Her research focuses on severe maternal morbidity, maternal mortality, postpartum patient safety, and contraception.
Biography
Andrei Stefanescu, PhD, MS, is an epidemiologist at the Los Angeles County Department of Public Health, leading the Data Analytics Team in the Acute Communicable Disease Control division. His work focuses on neonatal health, quality improvement, and most recently COVID-19 surveillance.
Biography
Lisa Romero, DrPH, MPH, is a Health Scientist in the Division of Reproductive Health, Centers for Disease Control and Prevention. Her work focuses on increasing contraception access, improving the management and care for pregnant and postpartum people, and health systems transformation.
Biography
Ekwutosi Okoroh, MD, is a Medical Officer and team lead in the Division of Reproductive Health, Centers for Disease Control and Prevention. Her work focuses on promoting and improving the health and well-being of women, children, and families by building MCH epidemiology and workforce capacity at state, local, and tribal levels.
Biography
Shanna Cox, MSPH, serves as the Associate Director for Science, for the Division of Reproductive Health, in the Centers for Disease Control and Prevention and is responsible for the management, monitoring, and evaluation of an expanding and diverse scientific portfolio.
Biography
Lyn Kieltyka, PhD, MPH, is the Senior Epidemiologist assigned to the Louisiana Department of Health through the Field Support Branch, Division of Reproductive Health, Centers for Disease Control and Prevention. Her work focuses on improving access to care and health outcomes.
Biography
Charlan D. Kroelinger, PhD, is the Chief of the Maternal and Infant Health Branch in the Division of Reproductive Health, Centers for Disease Control and Prevention. She supports work in maternal and infant health using implementation science and health services research.
Article info
Publication history
Published online: December 01, 2022
Accepted:
October 10,
2022
Received in revised form:
September 28,
2022
Received:
February 9,
2022
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2022 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.
