Fulfillment of Desired Postpartum Permanent Contraception: a Health Disparities Issue

Uncertainty in Postpartum Permanent Contraception Decision-Making: Physician and Patient Perspectives

PURPOSE

We sought to understand how patients and physicians conceptualize uncertainty in the permanent contraception decision-making process.

BASIC PROCEDURES

In 2022-2023, we interviewed postpartum patients with a documented desire for permanent contraception (n = 81) and their delivering physicians (n = 67). Eligible patients gave birth at one of our four study hospitals in California, Ohio, Illinois, and Alabama. We used rapid content analysis and thematic content analysis to develop and refine themes related to uncertainty in permanent contraceptive decision-making.

MAIN FINDINGS

Most patients reported full certainty in their decision regarding permanent contraception, although some expressed doubts. After receiving permanent contraception, some patients discussed grief but overall affirmed their decision. One patient said they wished they had considered other contraceptive options. Physicians reported using a range of strategies to safeguard from patient regret, including ensuring patients were 100% certain with their decision, inferring certainty based on their characteristics, asking patients to think through all scenarios that could affect decision-making, and repeat counseling during multiple interactions.

PRINCIPAL CONCLUSIONS

Patient experiences reveal the depth, fluidity, and nuance of patients' contraceptive decision-making processes. Physicians sometimes failed to grapple with this nuance by centering potential regret in their counseling. Personalized and supportive contraceptive counseling that acknowledges the complexity of contraceptive decision-making is imperative. Shared decision-making can help ensure patients can make informed and autonomous decisions about their reproductive lives.

Fulfillment of Permanent Contraception among Patients with Cesarean Delivery in a Multi-Site Cohort

OBJECTIVES

This study aimed to assess the association between insurance type and permanent contraception fulfillment among those with cesarean deliveries. Additionally, we sought to examine modification by the scheduled status of the cesarean.

STUDY DESIGN

We used data from a multi-site cohort study of patients who delivered in 2018-2019 at Northwestern Memorial Hospital in Illinois, MetroHealth Medical System in Ohio, or University of Alabama at Birmingham in Alabama. All patients had permanent contraception as their contraceptive plan in their medical chart during delivery hospitalization. We used logistic regression to model the association between insurance type, scheduled status of cesarean and permanent contraception fulfillment by hospital discharge. The scheduled status of cesarean delivery was examined as an effect modifier.

RESULTS

Compared to patients with private insurance, those with Medicaid were less likely to have their desired permanent contraception procedure fulfilled by hospital discharge (89.3% vs. 96.8%, p < 0.001). After adjusting for covariates, patients with Medicaid had a lower odds of permanent contraception fulfillment by hospital discharge (OR: 0.41; 95% CI: 0.21, 0.77). This association was stronger among those who had unscheduled cesarean deliveries (OR: 0.29; 95% CI: 0.12, 0.74) than those with scheduled cesarean deliveries (OR: 0.77; 95% CI: 0.32, 1.88).

CONCLUSIONS FOR PRACTICE

Compared to patients with private insurance undergoing a cesarean delivery, those with Medicaid insurance were less likely to have their desired permanent contraception fulfilled. Physicians and hospitals must examine their practices surrounding Medicaid forms to ensure that patients have valid consent forms available at the time of delivery.

Ongoing contraceptive goals of patients who did not achieve desired postpartum permanent contraception prior to hospital discharge

OBJECTIVE

To evaluate reasons for non-fulfillment and ongoing contraceptive plans of patients who desired but did not receive inpatient postpartum permanent contraception (PC).

STUDY DESIGN

Multi-site retrospective cohort study of 1254 patients with unfulfilled inpatient postpartum PC. We analyzed the reason for PC non-fulfillment, documented contraceptive plan, and method prescription or provision at hospital discharge, six-weeks, and one-year postpartum.

RESULTS

In our cohort, 44.3% of patients with unfulfilled inpatient PC did not receive any highly- or moderately-effective contraception within one year postpartum.

CONCLUSIONS

Removing barriers to PC fulfillment as well as contraceptive counseling that acknowledges these barriers is imperative.

Modeling the impact of decreasing waiting period length for Medicaid sterilization: A multi-site cohort study

OBJECTIVE

To evaluate the impact of length of the Medicaid sterilization waiting period and postpartum permanent contraception fulfillment.

STUDY DESIGN

Simulations from a retrospective cohort study estimating the potential increase in permanent contraception within 365 days of delivery.

RESULTS

In our sample of 2076 patients, 61% achieved permanent contraception with the current waiting period of 30 days. With the waiting period hypothetically reduced to 15, 3, 1, and 0 days, 62.9%, 63.7%, 64.5%, and 75% patients, respectively, would have achieved permanent contraception.

CONCLUSIONS

As potential Medicaid sterilization policy revisions are considered, understanding the impact on fulfillment rates is critical.

National Postpartum Permanent Contraception Practices and Perceived Barriers

Single institution-level studies have demonstrated low postpartum permanent contraception fulfillment rates after vaginal birth. To explore the national scope of the problem, we collected cross-sectional survey data from faculty at 109 U.S. academic medical centers to elicit perceptions about postpartum permanent contraception practices after vaginal birth, including barriers to and changes in practice after the Dobbs v Jackson Women's Health Organization decision, a decision that eliminated the U.S. federal protection of the right to abortion. Of 68 respondent institutions, 65 (95.6%) offered postpartum permanent contraception. A large majority (87.3%) perceived there to be a problem with postpartum permanent contraception fulfillment at their institution. Respondents at institutions with postpartum permanent contraception fulfillment rates in the bottom quartile used main operating rooms (66.7% vs 25.0% respectively, P =.032) and reported institutional culture barriers (86.7% vs 50.0%, respectively, P =.054) more frequently than respondents in the top quartile. Our national data indicate that health care culture changes and the use of labor and delivery operating rooms could increase postpartum permanent contraception fulfillment.

Evaluating feedback from an implementation advisory board to assess the rollout of a postpartum patient navigation program

BACKGROUND

Patient navigation is an individualized intervention to facilitate comprehensive care which has not yet been fully implemented in obstetric or postpartum care.

METHODS

We aimed to develop and evaluate a mechanism to incorporate feedback regarding implementation of postpartum patient navigation for low-income birthing individuals at an urban academic medical center. This study analyzed the role of an Implementation Advisory Board (IAB) in supporting an ongoing randomized trial of postpartum navigation. Over the first 24 months of the trial, the IAB included 11 rotating obstetricians, one clinic resource coordinator, one administrative leader, two obstetric nurses, one primary care physician, one social worker, and one medical assistant. Members completed serial surveys regarding program implementation, effects on patient care, and areas for improvement. Quarterly IAB meetings offered opportunities for additional feedback. Survey responses and meeting notes were analyzed using the constant comparative method and further interpreted within the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework.

RESULTS

Members of the IAB returned 37 surveys and participated in five meetings over 24 months. Survey analysis revealed four themes among the inner context: reduced clinician burden, connection of care teams, communication strategies, and clinic workflow. Bridging factors included improved patient access to care, improved follow-up, and adding social context to care. Innovation factors included availability of navigators, importance of consistent communication, and adaptation over time. Meeting notes highlighted the importance of bidirectional feedback regarding implementation, and members expressed positive opinions regarding navigators' effects on patient care, integration into clinic workflow, and responsiveness to feedback. IAB members initially suggested changes to improve implementation; later survey responses demonstrated successful program adaptations.

CONCLUSIONS

Members of an implementation advisory board provided key insights into the implementation of postpartum patient navigation that may be useful to promote dissemination of navigation and establish avenues for the engagement of implementing partners in other innovations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03922334 . Registered April 19, 2019. The results here do not present the results of the primary trial, which is ongoing.

Strategies for obstetricians and gynecologists to advance reproductive autonomy in a post-Roe landscape

The monumental reversal of Roe vs Wade dramatically impacted the landscape of reproductive healthcare access in the United States. The decision most significantly affects communities that historically have been and continue to be marginalized by systemic racism, classism, and ableism within the medical system. To minimize the harm of restrictive policies that have proliferated since the Supreme Court overturned Roe, it is incumbent on obstetrician-gynecologists to modify practice patterns to meet the pressing reproductive health needs of their patients and communities. Change will require cross-discipline advocacy focused on advancing equity and supporting the framework of reproductive justice. Now, more than ever, obstetrician-gynecologists have a critical responsibility to implement new approaches to service delivery and education that will expand access to evidence-based, respectful, and person-centered family planning and early pregnancy care regardless of their practice location or subspecialty.

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

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.

Racial and ethnic disparities in long-term contraception use among the birthing population at an academic hospital in the Southeastern United States

Ensuring women and birthing people have access to the contraceptive of their choice is essential for patient-centered care, health equity, and reproductive justice. While trends in national data in the United States reveal racial disparities in long-term contraceptive use, health-system and hospital-level investigations are essential to understand disparities and encourage interventions. We used data from 5011 patients who delivered at a large academic hospital to determine the effect of race/ethnicity and social vulnerability index (SVI) on the odds of undergoing a long-term contraceptive procedure. Results indicate that SVI substantially affects the odds of long-term contraception for non-Hispanic White women and birthing people. In contrast, Hispanic and non-Hispanic Black women and birthing people have significantly higher odds of undergoing a long-term contraceptive procedure due to race/ethnicity. Contributions to these disparities may be based on factors including healthcare providers, organizational and external policies. Interventions at all levels of care are essential to address disparities in contraceptive care, outcomes, and patient experience.

Non-Hormonal Contraception

While hormonal contraceptives are efficacious and available in several forms for women, perception of safety and concern over side effects are a deterrent for many. Existing non-hormonal contraceptives include permanent sterilization, copper intrauterine devices (IUDs), chemical/physical barriers such as spermicides and condoms, as well as traditional family planning methods including withdrawal and the rhythm method. Individuals who wish to retain their fertility in the future can achieve highest adherence and efficacy with long-acting, reversible contraceptives (LARCs), though there is only one, the copper IUD, that is non-hormonal. As rates of unintended pregnancies remain high with existing contraceptive options, it is becoming increasingly attractive to develop novel pregnancy prevention methods for both women and men. Non-hormonal contraceptives can target a variety of critical reproductive processes discussed here. This review focuses on identified non-hormonal contraceptive targets and subsequent drug candidates in development.

Medicaid and Fulfillment of Postpartum Permanent Contraception Requests

OBJECTIVE

To evaluate the association between Medicaid insurance and fulfillment of postpartum permanent contraception requests.

METHODS

We conducted a retrospective cohort study of 43,915 patients across four study sites in four states, of whom 3,013 (7.1%) had a documented contraceptive plan of permanent contraception at the time of postpartum discharge and either Medicaid insurance or private insurance. Our primary outcome was permanent contraception fulfillment before hospital discharge; we compared individuals with private insurance with individuals with Medicaid insurance. Secondary outcomes were permanent contraception fulfillment within 42 and 365 days of delivery, as well as the rate of subsequent pregnancy after nonfulfillment. Bivariable and multivariable logistic regression analyses were used.

RESULTS

Patients with Medicaid insurance (1,096/2,076, 52.8%), compared with those with private insurance (663/937, 70.8%), were less likely to receive desired permanent contraception before hospital discharge (P≤.001). After adjustment for age, parity, weeks of gestation, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index, private insurance status was associated with higher odds of fulfillment at discharge (adjusted odds ratio [aOR] 1.48, 95% CI 1.17-1.87) and 42 days (aOR 1.43, 95% CI 1.13-1.80) and 365 days (aOR 1.36, 95% CI 1.08-1.71) postpartum. Of the 980 patients with Medicaid insurance who did not receive postpartum permanent contraception, 42.2% had valid Medicaid sterilization consent forms at the time of delivery.

CONCLUSION

Differences in fulfillment rates of postpartum permanent contraception are observable between patients with Medicaid insurance and patients with private insurance after adjustment for clinical and demographic factors. The disparities associated with the federally mandated Medicaid sterilization consent form and waiting period necessitate policy reassessment to promote reproductive autonomy and to ensure equity.

Does socioeconomic factors and healthcare coverage affect postpartum sterilization uptake in an urban, tertiary hospital?

BACKGROUND

Postpartum sterilization in Thailand has relatively few barriers compared to other countries. The procedure is covered by some healthcare plans, and paid out-of-pocket for others. We aim to determine if healthcare coverage and other socioeconomic factors affect the rate of postpartum sterilization in an urban, tertiary hospital.

METHODS

We conducted a secondary analysis of data from a retrospective cohort of 4482 postpartum women who delivered at our hospital. Multivariable logistic regression was conducted to determine if sterilization reimbursement affects immediate postpartum sterilization rate.

RESULTS

Overall immediate postpartum sterilization rate was 17.8%. Route of delivery and parity were similar in those who were reimbursed and those who were not. Women aged over 25 were more likely to have a healthcare plan that does not cover postpartum sterilization. Women whose healthcare plan reimbursed the procedure trended towards postpartum sterilization when compared to women who were not (aOR 1.05, 95% CI 0.86-1.28, p-value = 0.632). Women who delivered via cesarean section were more likely to undergo sterilization at the time of delivery (aOR = 5.87; 95% CI 4.77-7.24, p-value = < 0.001). Women aged 40-44 years were 2.70 times as likely to choose sterilization than those aged 20-24 years (aOR = 2.70; 95% CI 1.61-4.53, p-value < 0.001).

CONCLUSIONS

Healthcare coverage of the procedure was not associated with increased postpartum sterilization in our setting.

Shared Decision-Making: The Way Forward for Postpartum Contraceptive Counseling

There are multi-level barriers that impact uptake of postpartum contraception and result in disparities, including clinical barriers such as provider bias. Fortunately, clinicians have direct control over their contraceptive counseling practices, and thus reducing structural barriers is actionable through high quality contraceptive counseling that equips patients with the knowledge and guidance they need to fulfill their reproductive desires. Yet, many commonly employed contraceptive counseling strategies, like One Key Question and WHO tiered contraceptive counseling, are not patient-driven, do not account for the important nuances of contraceptive choices, and are not focused specifically on the postpartum period. Given the history of eugenics and reproductive coercion in the US, supporting patient through their contraceptive decision-making process is especially vital. Additionally, contraceptive preferences vary based on patient-level factors and fluctuate over time and counseling should account for such differences. Shared contraceptive decision-making occurs when patients provide input on their values, desires, and preferences and clinicians share medical knowledge and evidence-based information without judgement. This approach is considered the most ethically sound form of counseling, as it maximizes patient autonomy. Shared decision-making also has clinical benefits, including increased patient satisfaction. In sum, shared contraceptive decision-making should be universally adopted to promote ethical, high-quality care and reproductive autonomy.