The Availability and Use of Postpartum LARC in Mexico and Among Hispanics in the United States

Views and experiences of long-acting reversible contraception among ethnic minorities in high-income countries: a systematic review of qualitative studies

BackgroundEthnic minorities in high-income countries have higher rates of unintended pregnancies but are less likely to use highly efficacious long-acting reversible contraception (LARC). The reasons for this are unclear.

AIM

To understand the views and experiences of ethnic minorities within high-income countries about LARC.

METHODOLOGY

Medline, CINAHL, EMBASE and Sociological Abstracts were searched systematically to find qualitative articles about views on LARC. Titles and abstracts were screened to select qualitative studies about LARC whose participants were mainly from ethnic minorities in high-income countries. Quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) tool. Thematic synthesis was conducted.

RESULTS

Seventeen studies (19 articles) met the inclusion criteria, 14 of which were from the USA (227 participants identified as Latina, 222 Black, 15 multiracial, 4 Asian). Two studies included 32 Chinese women in the UK and Australia and one included 20 Aboriginal women in Australia. Factors influencing uptake of LARC included side effects, convenience, and perceived efficacy of LARC compared with other methods; women's ideas, concerns and expectations; and external influences (partner, family/friends, health professionals and society). Convenience of LARC, control over reproductive decisions, and desire to prevent pregnancy were the main facilitators. Barriers included specific cultural concerns about irregular bleeding, concerns about racial discrimination, and family/friends having negative views on LARC.

CONCLUSIONS

Ethnic minority women often have additional needs and concerns about LARC compared with the White majority. Further research is needed to develop and evaluate customised respectful counselling on contraception options for ethnic minority women and their partners.

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation

BACKGROUND

Immigrant women's challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women's possibility to choose and initiate effective contraceptive methods post-partum.

METHODS

This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study's intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women's choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women's experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project's primary outcome involving women's choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents.

DISCUSSION

The intervention's co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services.

TRIAL REGISTRATION

NCT05521646, August 30, 2022.

Continuous quality improvement strategy for increasing immediate postpartum long-acting reversible contraceptive use at Jimma University Medical Center, Jimma, Ethiopia

BACKGROUND

Even though the immediate postpartum period is a golden time and a great opportunity to provide long-acting reversible contraceptives to prevent unintended pregnancy, its utilisation is very low in Ethiopia. Quality of care in postpartum long-acting reversible contraceptive provision is thought to be an issue for this low utilisation. Thus, continuous quality improvement intervention is necessary to increase the use of postpartum long-acting reversible contraceptives at Jimma University Medical Center.

METHOD

A quality improvement intervention to offer long-acting reversible contraceptive methods to immediate postpartum women at Jimma University Medical Center was initiated in June 2019. To study the baseline prevalence of long-acting reversible contraceptive use at Jimma Medical Centre over 8 weeks, we reviewed postpartum family planning registration logbooks and patients' charts. Based on the baseline data, the quality gaps were identified, prioritised and change ideas were generated and tested over another 8 weeks towards achieving the immediate postpartum long-acting reversible contraceptive prevalence target set.

RESULT

This new intervention resulted in an average increase in immediate postpartum long-acting reversible contraceptive methods use from 6.9% to 25.4% by the end of the project intervention. The major barriers to low long-acting reversible contraceptive use were lack of attention from hospital administrative staff and quality improvement teams on the provision of long-acting reversible contraceptives, lack of training of healthcare providers on postpartum contraception and unavailability of contraception commodities at each postpartum service delivery points.

CONCLUSION AND RECOMMENDATIONS

The immediate postpartum long-acting reversible contraceptive use at Jimma Medical Centre was increased by training of healthcare providers, availing contraception commodities through administrative staff involvement, weekly audit and feedback on contraception use. Thus, training of the newly hired healthcare providers on postpartum contraception, involvement of hospital administrative staff, regular audits and feedback on contraception use is necessary to increase postpartum long-acting reversible contraception uptake.

Adolescent Reproductive Health Outcomes Among Mexican-Origin Women on Both Sides of the U.S.-Mexico Border

PURPOSE

Much reproductive health research on the Latina population overlooks heterogeneity by national origin, nativity, and age and also ignores how U.S.-based populations differ from those in "sending" nations. The purpose of this study is to describe a history of adolescent birth, age at first sex, and contraceptive use at first sex in the Mexican-origin population in both the United States and Mexico.

METHODS

We developed a binational dataset merging two comparable nationally representative cross-sectional surveys in the United States and Mexico and used covariate balancing propensity scores to balance the age structure of our four samples: U.S.-born Latinas of Mexican origin, foreign-born Latinas of Mexican origin, U.S.-born non-Latina Whites, and Mexican women residing in Mexico. We used a negative binomial regression and calculated the predicted probability of experiencing at least one adolescent birth for each ethnicity/nativity group, stratified by 5-year age group. We also described age and contraceptive use at first sex.

RESULTS

Foreign-born Latinas of Mexican origin and Mexicans in Mexico had similar adjusted probabilities of reporting an adolescent birth (30.1% and 29.9%, respectively), which were higher than those of Mexican-Americans (26.2%) and U.S.-born non-Latina Whites (11.6%). History of an adolescent birth is declining across all four groups among younger ages. Differences do not appear to be driven by the timing of first sex but by contraceptive use, which is increasing among younger age groups.

DISCUSSION

Access to and use of effective contraception rather than timing of initiation of sexual activity is a key determinant of U.S. Latina and Mexican adolescent births.

Satisfaction, Resignation, and Dissatisfaction with Long-Acting Reversible Contraception among Low-Income Postpartum Texans

INTRODUCTION

Prior longitudinal studies of long-acting reversible contraception (LARC) satisfaction and continuation guaranteed their participants access to LARC removal. Under real-world conditions, LARC users who wish to discontinue may experience barriers to LARC removal.

METHODS

A prospective cohort study recruited 1,700 postpartum Texans without private insurance from 8 hospitals in 6 cities. Our analysis included the 418 respondents who initiated LARC in the 24 months after childbirth. A content analysis of open-ended survey responses identified three categories of LARC users: satisfied, resigned, and dissatisfied. Satisfied LARC users were using their method of choice. Resigned users were using LARC as an alternative method when their preferred method was inaccessible. Dissatisfied users were unhappy with LARC. Multinomial logistic regression models identified risk factors for resignation and dissatisfaction. Cox proportional hazards models assessed differences in LARC discontinuation by satisfaction and sociodemographic characteristics.

RESULTS

Participants completed 1,505 surveys while using LARC. LARC users were satisfied in 83.46% of survey responses, resigned in 5.25%, and dissatisfied in 11.30%. Resignation was more likely if respondents were uninsured or wanted sterilization at the time of childbirth. The risk of dissatisfaction increased with time using LARC and was higher among uninsured respondents. U.S.-born Hispanic LARC users were more likely than foreign-born Hispanic LARC users to be dissatisfied and less likely to discontinue when dissatisfied. Dissatisfaction-but not resignation-predicted discontinuation. Cost, lack of insurance, and difficulty obtaining an appointment were frequent barriers to LARC removal.

CONCLUSIONS

Most postpartum LARC users were satisfied, but users who wished to discontinue frequently encountered barriers.

Utilization of Immediate Postpartum Long Acting Reversible Contraceptives among Women Who Gave Birth in Public Health Facilities in Eastern Ethiopia: A Cross-Sectional Study

OBJECTIVE

Although importance of postpartum family planning is essential and immediate postpartum insertion of long acting and reversible contraceptives (LARC) is recommended, evidence on its uptake and associated factors is limited in Ethiopia. This study was conducted to assess utilization of immediate postpartum LARC among women who gave birth in selected public health facilities in eastern Ethiopia.

METHOD

An institution-based cross-sectional study was conducted among randomly selected women who gave birth in selected public health facilities in eastern Ethiopia from 10 March to 09 April 2020. At discharge, all eligible women who gave birth in the facilities were interviewed using a pretested structured questionnaire. Data were entered using EpiData 3.1 and analyzed using SPSS 24. Bivariable and multivariable logistic regression analyses were conducted to identify factors associated with utilization of immediate postpartum LARC. Adjusted odds ratio (aOR) with 95% confidence interval was used to report association, and significance was declared at p value < 0.05.

RESULTS

From a total of 546 women invited to the study, 530 (97.1%) participated in the study and 98 (18.5%; 95% CI: 15.1%, 22.0%) reported starting long acting reversible contraceptives. Women who reported discussing about contraceptives with partners (aOR = 6.69, 95% CI: 3.54, 12.61) and receiving postpartum counselling on contraceptives (aOR = 5.37, 95% CI: 3.00, 9.63) were more likely to using contraception. However, women who live >30-minute walking distance from the nearest health facility (aOR = 0.47, 95% CI: 0.26, 0.85) and reported disrespect and abuse during childbirth (aOR = 0.22, 95% CI: 0.12, 0.40) were less likely to start LARC.

CONCLUSIONS

Almost one in five women delivering in public health facilities in eastern Ethiopia started using LARC. Provision of respectful maternity care including counselling on the importance of immediate postpartum family planning is essential for increasing its uptake.

Using the Social-Ecological Model to Understand the Current Perspective of Contraceptive Use in the United States: A Narrative Literature Review

Contraceptive use is deemed one of the 10 greatest public health achievements of the 20th century because its benefits are universally acknowledged as a cornerstone for reducing global maternal morbidity and mortality. However, although the adoption of the Affordable Care Act in the United States (US) enhanced access to preventive health services, as well as increased contraceptive use, a considerable proportion of reproductive-aged women still have unmet reproductive health needs. Current data indicates gaps in contraceptive use patterns in the US, particularly among low-income women and those from racial/ethnic and gender minority subgroups, necessitating further investigation using an ecological approach. This narrative literature review aims to investigate the current perspective of contraceptive use in the US using the social-ecological model (SEM). Based on SEM levels, barriers to contraceptive use entail the following levels: individual (e.g., misbelief about the side effects of contraceptives), interpersonal (e.g., influence of family and friends), institutional (e.g., lack of training on how to use different types of contraceptives), community (e.g., societal stigma and shame), and policy (e.g., restrictive federal and states policies). Access to contraceptives for women is a system-level issue that necessitates consideration for multilevel strategies by key stakeholders to improve contraceptive uptake among vulnerable populations.

Patients' Experiences with an Immediate Postpartum Long-Acting Reversible Contraception Program

INTRODUCTION

We compared the characteristics of postpartum women who recalled being offered or not offered intrauterine devices and implants and who obtained placement of these long-acting reversible contraceptive (LARC) devices at a county hospital before discharge. We assessed satisfaction and continuation among those who obtained LARC methods.

METHODS

We interviewed 199 patients who delivered at a Texas hospital and tested for differences in who recalled being offered/not offered immediate postpartum LARC. We provide descriptive statistics on when offered and satisfaction, and assess continuation using Kaplan-Meier survival curves.

RESULTS

There were 103 of 199 women (51.8%) who recalled providers offering them immediate postpartum LARC; English-speaking relative to Spanish-speaking Hispanic women had higher odds of recounting being offered immediate postpartum LARC (adjusted odds ratio [OR], 3.88; 95% confidence interval [CI], 1.33-11.23), as did women with two children versus one child (OR, 3.64; 95% CI, 1.13-11.67). Compared with women 18-24 years of age who wanted more children, women 30-34 years of age who wanted more children had lower odds (OR, 0.14; 95% CI, 0.03-0.59), as did sterilized women 18 to 44 (OR, 0.02; 95% CI, 0.00-0.10). Seventy-four women (37% of all and 72% of those who recalled being offered) received immediate postpartum LARC. Sixty percent of those who received immediate postpartum LARC recalled that they were first offered it during prenatal care. Satisfaction was high but decreased between 3 and 6 months postpartum, mainly owing to negative side effects. Continuation at 24 months postpartum was 76.9% (CI, 71.7%-81.4%), with no difference between intrauterine device and implant use.

CONCLUSIONS

Language barriers may have hindered equal access to immediate postpartum LARC for Spanish-speaking patients; younger patients were more likely to recall being offered immediate postpartum LARC, possibly owing to providers' implicit biases or greater demand for LARC versus sterilization. Using formal interpretation services and patient-centered decision making may improve patient access to the contraception methods most aligned with their values and preferences.

Maternal indicators to monitor hospitals in the Rede Cegonha: a proposal

The Rede Cegonha strategy was launched in 2011 by the federal government to improve pregnancy, delivery, postpartum care, and child development in the first two years of life, reduce maternal and child mortality, and expand women's sexual and reproductive rights. We propose seven new maternal indicators to improve obstetric care evaluation in the next assessment cycle. The new indicators are the use of Robson's classification to monitor cesarean rates, use of magnesium sulfate in cases of preeclampsia/eclampsia, pregnant women's use of calcium supplements, blood transfusions and hysterectomy in delivery/puerperium, management of puerperal sepsis, IUD insertions in the postpartum/post-abortion period, and obstetricians' continuing education. These indicators are based on robust scientific evidence and can reduce unnecessary cesarean sections, prevent maternal deaths and future unplanned pregnancies.

Mexico's Prospera Program and Indigenous Women's Reproductive Rights

In this study, I examine Indigenous women's autonomy and reproductive rights within Mexico's Prospera program. Prospera gave women living in poverty bimonthly cash stipends for complying with requirements argued to improve the health and welfare of their families, including attending regular appointments at the clinic. Although hailed as successful, Mexico's new administration recently eliminated the health care component, citing various abuses. Some policy experts argue that these claims are unfounded and have questioned how Mexico will now address the health care needs of marginalized populations. Drawing on more than 2 years of fieldwork (2012-2014) in a Mayan community in Chiapas, I present evidence of abusive practices related to reproductive health care based on direct observations and audio-recordings of clinical interactions and program operations in IMSS-Prospera. Furthermore, I show how the reproductive habitus that supported these actions was shaped by long-standing institutional habits and sociocultural factors that need to be directly addressed in present reforms.

Quality of postpartum contraceptive counseling and changes in contraceptive method preferences

OBJECTIVES

We examined the association between quality of postpartum contraceptive counseling and changes in contraceptive method preference between delivery and 3-months postpartum.

STUDY DESIGN

We used data from 1167 postpartum women delivering at eight hospitals in Texas who did not initiate contraception in the hospital. We conducted baseline and 3-month follow-up interviews to ask women about the method they would prefer to use at 6-months postpartum, postpartum contraceptive counseling, reproductive history, and demographic characteristics. We measured quality of postpartum contraceptive counseling with seven items related to satisfaction and information received. High-quality counseling was defined as meeting all seven criteria. We used logistic regression to predict the primary outcome of changes in preferred method by contraceptive counseling and described contraceptive counseling and changes in preferred method by demographic characteristics.

RESULTS

Receipt of high-quality postpartum contraceptive counseling was reported by 26%. At 3-months postpartum 70% of participants reported the same contraceptive preferences by category of effectiveness that they expressed at the time of delivery. Spanish-speaking, Hispanic foreign-born, and lower socioeconomic status women were less likely to receive high-quality counseling than their counterparts. High-quality counseling was associated with lower odds of preferring a less effective method (OR: 0.31, 95% CI: 0.18-0.52) and changing preference from an IUD or implant (OR: 0.34, 95% CI: 0.17-0.68).

CONCLUSIONS

High-quality postpartum contraceptive counseling is relatively rare and occurs less often among low SES and immigrant women. High-quality counseling appears to reinforce preferences for effective contraception.

IMPLICATIONS

Training healthcare providers to provide high-quality contraceptive counseling to all postpartum women may reduce contraceptive disparities related to race/ethnicity and social class.

Women's and healthcare professionals' views on immediate postnatal contraception provision: a literature review

OBJECTIVES

Provision of immediate postnatal contraception, including long-acting reversible contraceptive (LARC) methods, is increasingly identified and endorsed as a key strategy for reducing unplanned and rapid repeat pregnancies. This literature review aims to evaluatethe views of women and healthcare professionals regarding the receipt, initiation or delivery of these services.

METHODS

Databases (Embase, Medline, CINAHL, HMIC) were searched for relevant English language studies, from January2003 to December 2017. In addition, Evidence Search, Google Scholar and Scopus (citation search) were used to identify further literature. Other relevant websites were accessed for policies, guidance and supplementary grey literature.

RESULTS

There is clear guidance on how to deliver good-quality postnatal contraception to women, but the reality of service delivery in the UK does not currently meet these aspirations, and guidance on implementation is lacking. The available evidence on the provision of immediate postnatal contraception focuses more on clinical rather than patient-centred outcomes. Research on postnatal women's views is limited to receptivity to LARC and contraception counselling rather than what influences their decision-making process at this time. Research on views of healthcare professionals highlights a range of key systemic barriers to implementation.

CONCLUSIONS

While views of postnatal women and healthcare professionals are largely in support of immediate postnatal contraception provision, important challenges have been raised and present a need for national sharing of service commissioning and delivery models, resources and evaluation data. Provider attitudes and training needs across multidisciplinary groups also need to be assessed and addressed as collaborative working across a motivated, skilled and up-to-date network of healthcare professionals is viewed as key to successful service implementation.

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

CONTEXT

Early access to contraception may increase postpartum contraceptive use. However, little is known about women's experiences receiving their desired method at the first postpartum visit or how access is associated with use.

METHODS

In a 2014-2016 prospective cohort study of low-income Texas women, data were collected from 685 individuals who desired a reversible contraceptive and discussed contraception with a provider at their first postpartum visit, usually within six weeks of birth. Women's experiences were captured using open- and closed-ended survey questions. Thematic and multivariate logistic regression analyses were employed to examine contraceptive access and barriers, and method use at three months postpartum.

RESULTS

Twenty-three percent of women received their desired method at the first postpartum visit; 11% a prescription for their desired pill, patch or ring; 8% a method (or prescription) other than that desired; and 58% no method. Among women who did not receive their desired method, 44% reported clinic-level barriers (e.g., method unavailability or no same-day provision), 26% provider-level barriers (e.g., inaccurate contraceptive counseling) and 23% cost barriers. Women who used private practices were more likely than those who used public clinics to report availability and cost barriers (odds ratios, 6.4 and 2.7, respectively). Forty-one percent of women who did not receive their desired method, compared with 86% of those who did, were using that method at three months postpartum.

CONCLUSION

Eliminating the various barriers that postpartum women face may improve their access to contraceptives. Further research is needed to improve the understanding of clinic- and provider-level barriers.

Unmet demand for short-acting hormonal and long-acting reversible contraception among community college students in Texas

OBJECTIVE

To identify preferences for and use of short-acting hormonal (e.g., oral contraceptives, injectable contraception) or long-acting reversible contraception (LARC) among community college students in Texas.

PARTICIPANTS

Female community college students, ages 18 to 24, at risk of pregnancy, sampled in Fall 2014 or Spring 2015 (N = 966).

METHODS

We assessed characteristics associated with preference for and use of short-acting hormonal or LARC methods (i.e., more-effective contraception).

RESULTS

47% preferred short-acting hormonal methods and 21% preferred LARC, compared to 21% and 9%, respectively, who used these methods. A total of 63% of condom and withdrawal users and 78% of nonusers preferred a more effective method. Many noted cost and insurance barriers as reasons for not using their preferred more-effective method.

CONCLUSIONS

Many young women in this sample who relied on less-effective methods preferred to use more-effective contraception. Reducing barriers could lead to higher uptake in this population at high risk of unintended pregnancy.

Choice of contraception at 6-8 weeks postpartum in south-eastern Hungary

OBJECTIVES

The aims of the study were to describe the sociodemographic determinants, breastfeeding- and sexual life-related predictive factors of contraceptive use at 6-8 weeks postpartum.

METHODS

A prospective, web-based questionnaire survey was carried out by distributing an access code to women immediately after delivery at the Department of Obstetrics and Gynaecology, the University of Szeged, Szeged, Hungary, between 1 September 2013 and 1 May 2015.

RESULTS

In total, 1875 women were invited to participate in the study, 632 of whom refused or were excluded and 644 were not sexually active. The remaining sexually active women (n = 599) completed the questionnaire. At 6-8 weeks postpartum, 22.5% were using an effective contraceptive method and 40.2% were relying on lactational amenorrhoea (LAM). We found a significant direct association between the educational level of a woman's partner and her use of an effective contraceptive method (p < .001) (adjusted odds ratio [AOR]: 1.9) or LAM (AOR: 1.49). Use of an effective contraceptive method before pregnancy increased the likelihood of using the same method after delivery (AOR: 3.16) and decreased the likelihood of LAM use at weeks 6-8 (AOR: 0.31). The AOR for effective contraceptive use was 2.23 times higher in women who had sexual intercourse once or more a week compared with those who had sexual intercourse less frequently.

CONCLUSIONS

Concerted efforts to promote the use of long-acting reversible contraception (LARC) are required, particularly among women who would like future childbearing. Further research is needed on the factors contributing to the low uptake of LARC in this population.

Contraception After Delivery Among Publicly Insured Women in Texas: Use Compared With Preference

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 (1,367/1,700). Overall, preferences exceeded use for both-LARC: 40.8% (n=547) compared with 21.9% (n=293) and sterilization: 36.1% (n=484) compared with 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<.035) as it was for U.S.-born women (odds ratio [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<.001) and was lower for black women (OR 0.26, 95% CI 0.12-0.55) and higher for U.S.-born women (OR 2.32, 95% CI 1.36-3.96), those 30 years of age and older (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 health care 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.