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In the United States, approximately half of women who have recently had a baby use the least effective methods of contraception, including condoms and withdrawal, or no method at all. Unintended pregnancies often result – and pregnancies spaced less than eighteen months apart are associated with poor birth outcomes. If more women received long-acting reversible contraception shortly after birth – including intrauterine devices or implants – unintended pregnancies, abortions, and poorly timed pregnancies could all be reduced. But little is known about the kinds of contraception women would like to use after giving birth, and whether the limited use of highly effective methods corresponds with women’s preferences.
Our research assesses the demand for highly effective postpartum contraception, and compares it with the actual use of these contraceptive methods six months after delivery. Our study was conducted in Texas, a state where family planning funding was reduced in 2011 and Planned Parenthood was excluded from a state-funded fee-for-service program. Previous studies have found that restricting access to longer-term methods may prevent publicly insured women from getting access to the contraception methods they want.
Across the State, Contraceptive Preference Does Not Match Use
We surveyed women – 81 percent Hispanic, and about half not born in the United States – who had given birth to a single, healthy child at eight hospitals across six Texas cities. All participants had their births covered by public insurance or had no insurance; and all of them wanted to delay further childbearing for at least two years. Of the eight hospitals that participated in the study, only one (“hospital 8”) made it possible for new mothers to get long-acting reversible contraception immediately after delivery.
We asked women what method of contraception they were currently using, and which methods they would prefer. Our study focused especially on preferences for long-acting reversible methods, female sterilization, and vasectomy. Prior research has shown many women prefer these methods after birth, but are not using them because of high upfront costs and lack of availability at hospitals, health care clinics, and doctors’ offices. We asked women who attended a postpartum appointment if there was a method they wanted but were unable to get at the appointment. We also asked women who had not previously mentioned an interest in long-acting reversible contraception whether they would consider using an intrauterine device or implant if it were free. For women who wanted no more children and had not mentioned a preference for sterilization, we asked if they would like to have gotten their tubes tied after delivery.
Without any prompting from interviewers, women’s reported preference to gain access to long-acting reversible and hormonal methods was substantially greater than actual use – an indication that many patients had unmet needs. Asking women if they would like long-acting reversible contraception or sterilization led twice as many to indicate a preference for permanent methods – creating an even wider gap between preferences and use. Also, we found a large and significant difference between hospital 8, which offered long-lasting methods, and all the other hospitals, which did not. In hospital 8, 36 percent of participants took advantage of immediate postpartum long-acting reversible contraception, and their use of those methods remained near that level during the next six months after delivery. Compared to women at hospital 8, fewer women who gave birth at other hospitals were using long-acting reversible contraception at the time of their postpartum interviews; and a higher percentage of them relied on hormonal and less effective methods. In short, it mattered if a hospital offered long-lasting contraception.
How to Promote Effective Contraception Use
Our findings demonstrate that many more women had a preference for long-acting reversible contraception or sterilization than were actually using these methods six month after delivery. Furthermore, women at the one hospital that provided such forms of contraception after birth were much more likely to use these methods than women at the other hospitals in the study.
Failure to offer women all options is not the only issue. Undocumented immigrants who do not have insurance coverage for contraception after delivery are also not likely to gain access to preferred methods. In Texas, undocumented women may be eligible to receive prenatal and postpartum care through the perinatal program in the Children’s Health Insurance Program administered through Medicaid, which covers medical care related to the “unborn child.” These benefits include two postpartum visits, but contraception is not covered. Texas and other states should explore expanding the definition of postpartum services to include contraception, as Michigan recently did.
Undocumented women are not the only ones whose preferences were not realized. Non-Hispanic black women who did not want more children found it unusually hard to get access to long-lasting methods or sterilization – in part because, as previous studies show, healthcare providers are reluctant to perform sterilizations on such women. In addition, women who received prenatal care from a public clinic were more likely to use long-acting or permanent methods than those who obtained care from a private provider. Public clinic personnel may be more familiar with eligibility criteria and better able to provide counseling and access at reasonable prices.
Overall, our findings suggest that new mothers in public insurance programs in Texas make more limited use of long-acting and permanent contraceptive methods in the postpartum period than they would prefer. This situation could be remedied by providing better access to these methods and extending public perinatal programs to cover contraception for undocumented mothers. The overall result would be fewer unintended pregnancies and lower rates of abortion.