The impact of postpartum contraception on reducing preterm birth: findings from California

Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis

BACKGROUND

Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants.

OBJECTIVE

This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery.

STUDY DESIGN

A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies.

RESULTS

Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy.

CONCLUSION

The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.

California's Comprehensive Perinatal Services Program and birth outcomes

Introduction

California's Medicaid (Medi-Cal) sponsors Comprehensive Perinatal Services Program (CPSP), a program with enhanced perinatal care for women (more education, nutritional supplements, and psychosocial counseling/support). Past evaluations of CPSP's effectiveness in birth outcomes were limited to pilot programs and yielded mixed results.

Methods

We used 2012-2016 California's statewide data about singleton live births with any receipt of prenatal care (N = 2,385,811) to examine whether Medi-Cal with CPSP enrollment was associated with lower odds of preterm birth (PTB), spontaneous PTB, and low birthweight (LBW) than non-CPSP births. With three binary variables of PTB, spontaneous PTB, and LBW as the response variables, three multilevel logistic models were used to compare the outcomes of participants enrolled in Medi-Cal with CPSP against those with private insurance, adjusting for maternal factors and county-level covariates.

Results

Logistic models showed that participants enrolled to Medi-Cal with CPSP [n (%) = 89,009 (3.7)] had lower odds of PTB, spontaneous PTB and LBW, respectively, as compared with those with private insurance [n (%) = 1,133,140 (47.2)]. Within the Medi-Cal sub-population, the CPSP enrollment was associated with lower odds of PTB, SPTB and LBW than Medicaid beneficiaries without CPSP [n (%) = 967,094 (40.3)].

Discussion

With statewide data, these findings revealed a robust link between CPSP enrollment and better birth outcomes. Expanding access to comprehensive prenatal services could be an important strategy to improve birth outcomes.

Association of intrapartum severe maternal morbidity with receipt of postpartum contraception among Medicaid recipients

OBJECTIVES

We sought to determine the association between intrapartum severe maternal morbidity and receipt of postpartum contraception within 60 days among Medicaid recipients in Oregon and South Carolina.

STUDY DESIGN

We conducted a historical cohort study of all Medicaid births in Oregon and South Carolina from 2011 to April 2018. Intrapartum severe maternal morbidity was measured using diagnosis and procedure codes according to the Center for Disease Control's classifications. Our primary outcome of interest was receipt of postpartum contraception within 60 days of birth. We captured permanent and reversible forms of contraception. We examined the association of intrapartum severe maternal morbidity with receipt of postpartum contraception, and whether this varied by type of Medicaid (Traditional vs Emergency). We used Poisson regression models with robust (sandwich) estimation of variance to calculate relative risk (RR) for each model.

RESULTS

Our analytic cohort included 347,032 births. We identified 3079 births with evidence of intrapartum severe maternal morbidity (0.9% of all births). When adjusted for maternal age, rural vs urban status, and state of residence, Medicaid beneficiaries with births complicated by intrapartum severe maternal morbidity are 7% less likely to receive any contraception (RR 0.93, 95% CI (0.91, 0.95)) by 60 days postpartum. Among births complicated by severe maternal morbidity we found that Emergency Medicaid recipients were 92% less likely than Traditional Medicaid recipients to receive any method of contraception (RR 0.08, 95% CI (0.08, 0.08)).

CONCLUSIONS

Medicaid recipients experiencing intrapartum severe maternal morbidity are less likely to receive contraception within 60 days than Medicaid beneficiaries with uncomplicated births.

IMPLICATIONS

Medicaid recipients with intrapartum severe maternal morbidity are less likely to receive postpartum contraception, than Medicaid beneficiaries without severe maternal morbidity.

Rates of Preterm Birth and Low Birth Weight in an Adolescent Obstetric Clinic: Achieving Health Equity Through Trauma-Informed Care

Objectives

Adolescents who are pregnant and identify as Black are exposed to more societal harms that increase their and their offspring's risk for poor health outcomes. The Colorado Adolescent Maternity Program (CAMP) offers comprehensive, multidisciplinary (medical, behavioral health, nutrition, case management), trauma-informed obstetric care to pregnant adolescents to ensure the healthiest pregnancy and birth possible and pursue health equity. The present study aimed to examine ethnic and racial disparities in preterm birth and low birth weight before and after implementation of a trauma-informed model of care.

Methods

Participants were 847 pregnant adolescents (ages 12-22 years; 41% self-identified as Hispanic, 32% as non-Hispanic Black, 21% as non-Hispanic white) who received prenatal treatment-as-usual (TAU) or trauma-informed treatment. Demographic information, mental health symptoms, and birth outcomes were abstracted from medical records.

Results

Overall, findings provided support that implementation of a trauma-informed model of prenatal care led to equitable birth outcomes across racial and ethnic groups. Specifically, Black adolescents in the TAU group were more than twice as likely to deliver preterm or low birth weight infants compared with white and Hispanic adolescents. In the trauma-informed group, however, there were no statistical differences in birth outcomes across racial/ethnic groups, indicating an elimination of disparities in both preterm birth and low birth weight in this population. These more equitable birth outcomes occurred even in the context of adolescents of color having reported more severe depression symptoms postimplementation.

Conclusions

These findings provide evidence that a health system-level intervention, herein trauma-informed obstetric care for adolescents, can play a meaningful role in the reduction of racial disparities in birth outcomes.

Future Pregnancy Considerations after Premature Birth of an Infant Requiring Intensive Care: A Qualitative Study

BACKGROUND

Postpartum contraception counseling and method use vary widely among patients who had a preterm birth. We performed this study to explore what issues and concerns individuals with preterm infants requiring intensive care describe as influencing their postpartum contraceptive choices.

METHODS

We conducted a qualitative study using semi-structured interviews with participants who gave birth to a singleton preterm infant admitted to the neonatal intensive care unit (NICU). We explored pregnancy, childbirth, postpartum care, and NICU experiences, as well as future reproductive plans and postpartum contraceptive choices. Two coders used a constant-comparative approach to code transcripts and identify themes.

RESULTS

We interviewed 26 participants: 4 (15%) gave birth at less than 26, 6 (23%) at 26 to 27 6/7, 8 (31%) at 28 to 31 6/7, and 8 (31%) at 32 to 36 6/7 weeks of gestation. We identified three main themes related to future pregnancy plans and contraception choice. First, participants frequently described their preterm birth and their infants' NICU hospitalization as traumatic experiences that affected plans for future pregnancies. The loss of control in predicting or preventing a future preterm birth and uncertainty about their premature child's future medical needs resulted in participants wanting to avoid going through the same experience with another child. Second, participants chose contraception based on previous personal experiences, desired method features, and advice from others. Last, having a preterm birth did not result in any ambivalence among those who desired permanent contraception.

CONCLUSIONS

Preterm birth influences future pregnancy plans. When discussing reproductive goals with patients, clinicians should be aware of potential trauma associated with a premature birth, assess for whether patients want to discuss contraception, and center the conversation around individual needs if patients do desire contraceptive counseling.

Short-Interval Pregnancy in the Illinois Medicaid Population Following Delivery in Catholic vs non-Catholic Hospitals

OBJECTIVE

Catholic hospitals restrict access to comprehensive reproductive health services that could impact patient outcomes. We sought to determine whether delivery at a Catholic hospital is associated with shorter pregnancy intervals among patients insured by Medicaid in Illinois.

STUDY DESIGN

We used Illinois Medicaid data files to conduct a retrospective cohort study. We used billing codes to identify deliveries in 2010 and 2011 and classified each by hospital of delivery, maternal age, race/ethnicity, and residential zip code. We calculated the interval from index birth to subsequent conception using an established method, and used Cox proportional hazards regression to compare the rate of subsequent pregnancy between enrollees who delivered in Catholic vs non-Catholic hospitals, adjusting for individual characteristics. We also computed differences in the rates of conception within 6, 12 and 18 month intervals.

RESULTS

We identified 96,293 index births and 18,627 subsequent conceptions. Twenty eight percent (26,775) of index births occurred in a Catholic hospital. Women who delivered in a Catholic hospital had a 12% greater risk of conception in the following 18 months (HR 1.12, 95% CI 1.09-1.16) after adjusting for age, race/ethnicity and rural residence. At 18 months, 23.9% of enrollees delivering in a Catholic hospital had become pregnant as compared to 21.2% for enrollees delivering in a non-Catholic hospital (difference of 2.6%, 95% CI 1.8-3.6).

CONCLUSION

Illinois Medicaid enrollees who deliver at Catholic hospitals have an increased risk of short-interval pregnancy. As the market share of Catholic hospitals grows, providers must work with patients to acknowledge and address these potential impacts on reproductive health outcomes and policies must change to promote equitable access.

IMPLICATIONS

Delivery at a Catholic hospital is associated with increased risk of short-interval pregnancy. Further attention from providers, researchers and policy makers alike, is necessary to identify the mechanisms through which these differences manifest such that effective interventions can be developed.

Association of Medicaid Reimbursement for Immediate Postpartum Long-acting Reversible Contraception With Infant Birth Outcomes

IMPORTANCE

Together, preterm birth and low birth weight are the second-leading cause of infant mortality in the US and occur disproportionately among Medicaid-paid births and among the infants of Black birthing persons. In 2012, South Carolina's Medicaid program began to reimburse hospitals for immediate postpartum long-acting reversible contraception (LARC) separately from the global maternity payment.

OBJECTIVE

To examine the association between South Carolina's policy change and infant health.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study using a difference-in-differences analysis included individuals with a South Carolina Medicaid-paid childbirth between January 2009 and December 2015. Data were analyzed from December 2020 to July 2021.

EXPOSURES

Medicaid-paid childbirth after March 2012 in South Carolina hospitals that had implemented the policy.

MAIN OUTCOMES AND MEASURES

Immediate postpartum LARC uptake, subsequent birth within 4 years, subsequent short-interval birth, days to subsequent birth, subsequent preterm, and low-birth-weight birth within 4 years.

RESULTS

The study sample included 186 953 Medicaid-paid births between January 2009 and December 2015 in South Carolina (81 110 births from 2009 to 2011, 105 843 births from 2012 to 2015, and 46 414 births in exposure hospitals). The policy was associated with an absolute 5.6-percentage point (95% CI, 3.7-7.4) increase in the probability of receiving an immediate postpartum LARC overall, with significantly larger effects for non-Hispanic Black individuals than non-Hispanic White individuals (difference in coefficients 3.54; 95% CI, 1.35-5.73; P = .002). The policy was associated with a 0.4-percentage point (95% CI, -0.7 to -0.1) decrease in the probability of subsequent preterm birth and a 0.3-percentage point (95% CI, -0.7 to 0) decrease in the probability of subsequent low birth weight. No significant difference in the association between the policy and preterm birth or low-birth-weight birth between non-Hispanic Black and non-Hispanic White individuals was found. The policy was associated with a 0.6-percentage point (95% CI, -1.2 to -0.1) decrease in the probability of short-interval birth and a 27-day (95% CI, 11-44) increase in days to next birth among non-Hispanic Black individuals. The policy was associated with a significant decrease in the probability of a subsequent birth overall; however, confidence in this result is attenuated somewhat by nonparallel trends for this outcome before the policy change.

CONCLUSIONS AND RELEVANCE

Findings of this cohort study suggest policies increasing access to immediate postpartum LARC may improve birth outcomes but should be accompanied by other policy efforts to reduce inequity in these outcomes.

Analysis of Contraceptive Use Among Immigrant Women Following Expansion of Medicaid Coverage for Postpartum Care

IMPORTANCE

Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid.

OBJECTIVE

To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021.

EXPOSURES

Medicaid coverage of postpartum care.

MAIN OUTCOMES AND MEASURES

Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery.

RESULTS

The study population consisted of 27 667 live births among 23 971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21 289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20 042 births [72.4%]; SMD = 0.03) and at term (25 502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P < .001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.

Social disadvantage and its effect on maternal and newborn health

Social disadvantage impacts the health of women and newborns throughout the life course. Contributing factors such as low educational attainment, unemployment, poverty, and lack of health insurance disproportionately affects minority women of reproductive age in the United States. This article reviews social disadvantage as it contributes to health status and health disparities for mothers and newborns in the United States and highlights the opportunities to improve social and structural determinants of health to address these gaps.

Knowledge and utilization of family planning among rural postpartum women in Southwest Nigeria

Background:

In Nigeria, contraceptive use has remained low, 12% for any modern method, despite the huge resources committed to family planning programs by stakeholders. This study was carried out to assess the knowledge and utilization of family planning and determine predictors of utilization of family planning among postpartum women attending primary health care centers (PHCs) in a selected rural area of Lagos State, southwest Nigeria.

Methods:

This was a descriptive cross-sectional study conducted among 325 postpartum women attending PHCs in Ibeju-Lekki local government area of Lagos State selected using a multi-stage sampling technique. A pretested, interviewer-administered questionnaire was used to collate data which was analyzed using the IBM SPSS Statistics version 23.

Result:

The mean age was 29.94 ± 5.14 years. All the respondents (100%) had heard of contraceptive methods, however only 38 (11.7%) had good knowledge of family planning. About 38.5% of the respondents used modern family planning methods during the postpartum period. The most commonly used methods were male condoms (26.3%) and implants (17.0%). The significant predictors of postpartum family planning (PPFP) were non-intention to have more children [AOR = 1.88 (95% CI: 1.14–3.11)], and good knowledge of family [AOR = 2.31 (95% CI: 1.11–4.81)].

Conclusion:

It is recommended that interventions be designed to educate and advocate for the use of family planning methods not only to stop childbearing but also to space pregnancies. Education about family planning should also be intensified to improve knowledge of family planning, and thus practice.

Controversies in the prevention of spontaneous preterm birth in asymptomatic women: an evidence summary and expert opinion

Preterm birth prevention is multifaceted and produces many nuanced questions. This review addresses six important clinical questions about preterm birth prevention as voted for by members of the UK Preterm Clinical Network. The questions cover the following areas: preterm birth prevention in 'low-risk' populations; screening for asymptomatic genital tract infection in women at high risk of preterm birth; cervical length screening with cerclage or vaginal pessary in situ; cervical shortening whilst using progesterone; use of vaginal progesterone in combination with cervical cerclage; and optimal advice about intercourse for women at high risk of preterm birth.

Optimizing interconception care: Rationale for the IMPLICIT model

Despite traditional prenatal interventions, the incidence of low birth weight and prematurity in the United States have not significantly decreased. Interconception care for women between pregnancies has been proposed as a method of improving various perinatal outcomes. Although broadly advocated by national groups, interconception care (ICC) has not been widely implemented. We describe best practices for an ICC model based on screening mothers for tobacco use, depression, folic acid intake, and inter-pregnancy interval at well child visits. Because of the model's flexibility, sites can readily customize implementation by incorporating the questions directly into existing workflows and using local service providers already working in maternal-child health. This model has demonstrated promising results and ease of implementation thus far, and offers great potential for improved perinatal outcomes and promotion of health equity.

Universal access to contraception: women, families, and communities benefit

Universal access to contraception benefits society: unintended pregnancies, maternal mortality, preterm birth, abortions, and obesity would be reduced by increasing access to affordable contraception. Women should be able to choose when and whether to use contraception, choose which method to use, and have ready access to their chosen method. State and national government should support unrestricted access to all contraceptives. As obstetrician-gynecologists, we have a critical mandate, based on principle and mission, to step up with leadership on this vital medical and public health issue, to improve the lives of women, their families, and society. The field of Obstetrics and Gynecology must provide the leadership for moving forward. The American Gynecological and Obstetrical Society (AGOS), representing academic and public policy leaders from across all disciplines of Obstetrics and Gynecology, is well positioned to serve as a unifying organization, focused on developing a strong unified advocacy voice to fight for accessible contraception for all in the United States.

Experiences with Prenatal and Postpartum Contraceptive Services among Women with a Preterm Birth

BACKGROUND

Providing postpartum contraception can help to achieve recommended interpregnancy intervals (≥18 months from birth to next pregnancy), decrease the risk of preterm birth, and thus improve maternal and infant health outcomes of future pregnancies. However, the experiences of women with preterm birth regarding contraceptive services have not been documented. We sought to better understand contraceptive counseling experiences and postpartum contraception of women with a preterm birth.

METHODS

We interviewed 35 women, ages 18-42 years, with a recent preterm birth in California. The transcribed interviews were analyzed using ATLAS.ti v.8.

RESULTS

Women had public (n = 15), private (n = 16), or no insurance (n = 4) at the time of the interview. Women were mainly Latina (n = 14), Caucasian (n = 9), or African American (n = 6); 15 women were foreign born. Women's experiences ranged from spontaneous preterm births to births with severe medical complications. We identified five themes that were associated with women's engagement in the contraceptive method choice and understanding of birth spacing: 1) timing and frequency of contraceptive counseling; 2) quality of patient-provider interaction and ability to follow up on questions; 3) women's personal experiences with contraceptive use and experiences of other women; 4) context in which contraceptive counseling was framed; and 5) system barriers to contraceptive use.

CONCLUSIONS

Postpartum contraceptive counseling should address women's preterm birth experience, medical conditions, age, contraceptive preference, and childbearing plans. Having a preterm birth intensifies gaps in hospital and outpatient clinic coordination and provider-patient communication that can lead to use of less effective or no contraceptive methods and risk of early subsequent unplanned pregnancies.

Black-White Disparities in Preterm Birth: Geographic, Social, and Health Determinants

INTRODUCTION

Reducing racial/ethnic disparities in preterm birth is a priority for U.S. public health programs. The study objective was to quantify the relative contribution of geographic, sociodemographic, and health determinants to the black, non-Hispanic and white, non-Hispanic preterm birth disparity.

METHODS

Cross-sectional 2016 U.S. birth certificate data (analyzed in 2018-2019) were used. Black-white differences in covariate distributions and preterm birth and very preterm birth rates were examined. Decomposition methods for nonlinear outcomes based on logistic regression were used to quantify the extent to which black-white differences in covariates contributed to preterm birth and very preterm birth disparities.

RESULTS

Covariate differences between black and white women were found within each category of geographic, sociodemographic, and health characteristics. However, not all covariates contributed substantially to the disparity. Close to 38% of the preterm birth and 31% of the very preterm birth disparity could be explained by black-white covariate differences. The largest contributors to the disparity included maternal education (preterm birth, 11.3%; very preterm birth, 9.0%), marital status/paternity acknowledgment (preterm birth, 13.8%; very preterm birth, 14.7%), source of payment for delivery (preterm birth, 6.2%; very preterm birth, 3.2%), and hypertension in pregnancy (preterm birth, 9.9%; very preterm birth, 8.3%). Interpregnancy interval contributed a more sizable contribution to the disparity (preterm birth, 6.2%, very preterm birth, 6.0%) in sensitivity analyses restricted to all nonfirstborn births.

CONCLUSIONS

These findings demonstrate that the known portion of the disparity in preterm birth is driven by sociodemographic and preconception/prenatal health factors. Public health programs to enhance social support and preconception care, specifically focused on hypertension, may provide an efficient approach for reducing the racial gap in preterm birth.

Pregravid Oral Contraceptive Use and the Risk of Preterm Birth, Low Birth Weight, and Spontaneous Abortion: A Systematic Review and Meta-Analysis

Background: Although oral contraceptives (OCs) have been widely used by women of childbearing age, their influence on pregnancy and birth outcomes, such as preterm birth (PB), low birth weight (LBW), and spontaneous abortion (SAB), is unclear. The aim of this systemic review was to assess these complications in women who had used OCs before pregnancy compared with those in a control group. Materials and Methods: The databases of PubMed, EMBASE, and Web of Science were searched up to December 2018. We included studies where the primary outcome was the risk of PB, LBW, and SAB in women with pregravid OCs use compared with the control group. Odds ratio (OR) value was calculated to assess the risk. Results: Eighteen studies were included in the systematic review, and a total of 148,406 subjects from 7 studies were pooled for the meta-analysis. Results showed that the risk of PB was slightly higher in the exposed group (OR = 1.17, 95% confidence interval [CI] = 1.07-1.27, p = 0.0005); however, there was a lower risk for SAB compared with the control group (OR = 0.63, 95% CI = 0.41-0.96, p = 0.03). No significant difference was found in the incidence of LBW (OR = 1.36, 95% CI = 0.92-2.02, p = 0.12). Conclusions: This systematic review and meta-analysis demonstrated a higher risk for PB and a lower risk for SAB in women with previous ORs use, whereas no association was found between ORs use and LBW risk.

Health Care Barriers to Provision of Long-Acting Reversible Contraception in Wisconsin

INTRODUCTION

Long-acting reversible contraceptives (LARC), specifically implants and intrauterine devices (IUD), are highly effective, low maintenance forms of birth control. Practice guidelines from the American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American Academy of Pediatrics recommend that LARC be considered first-line birth control for most women; however, uptake remains low. In this study, we sought to understand practices and barriers to provision of LARC in routine and immediate postpartum settings as they differ between specialties.

METHODS

We surveyed 3,000 Wisconsin physicians and advanced-practice providers in obstetrics-gynecology/women's health (Ob-gyn), family medicine, pediatrics, and midwifery to assess practices and barriers (56.5% response rate). This analysis is comprised of contraceptive care providers (n=992); statistical significance was tested using chi-square and 2-sample proportions tests.

RESULTS

More providers working Ob-gyn (94.3%) and midwifery (78.7%) were skilled providers of LARC methods than those in family medicine (42.5%) and pediatrics (6.6%) (P < .0001). Lack of insertion skill was the most-cited barrier to routine provision among family medicine (31.1%) and pediatric (72.1%) providers. Among prenatal/delivery providers, over 50% across all specialties reported lack of device availability on-site as a barrier to immediate postpartum LARC provision; organizational practices also were commonly reported barriers.

CONCLUSIONS

Gaps in routine and immediate postpartum LARC practice were strongly related to specialty, and providers' experience heightened barriers to immediate postpartum compared to routine insertion. Skills training targeting family medicine and pediatric providers would enable broader access to LARC. Organizational barriers to immediate postpartum LARC provision impact many providers.

Adolescent Contraception Use after Pregnancy, an Opportunity for Improvement

STUDY OBJECTIVE

To describe contraceptive method use by adolescent women in the 6 months after any pregnancy.

DESIGN

We conducted a secondary analysis of the 2011-2013 and 2013-2015 cycles of the National Survey of Family Growth.

SETTING

This survey is a nationally-representative population-based survey of reproductive aged women in the United States.

PARTICIPANTS

The sample included respondents who had at least 1 pregnancy that ended within the contraceptive calendar period as well as before the month of the respondent's 20th birthday. Women were included even if they did not have a full 6 months' worth of data.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We examined contraception method use at 1, 2, 4, and 6 months post pregnancy regardless of pregnancy outcome (live birth, induced abortion, or miscarriage).

RESULTS

Our sample consisted of 337 women with a mean age of 18.5 years. Almost half (N = 158, weighted percentage = 43.5%) of adolescents were using no method of contraception at 1 month post pregnancy. By 6 months post pregnancy, only 143 of 287 women with data through 6 months (weighted percentage = 49.7%) were using more effective methods of contraception (long-acting reversible contraception or hormonal methods), and 83 of these 287 were using no method (weighted percentage = 29.2%), including 61 of 261 women who reported that their last pregnancy was unwanted. Women from racial and ethnic minorities were less likely to use the most effective contraceptive methods. Rapid repeat pregnancy occurred among 44 of 209 women in the subsample with 18 months' follow-up data (weighted percentage = 16.9%). Only 56 of 337 adolescents (weighted percentage = 19.0%) used long-acting reversible contraceptive methods at any time post pregnancy regardless of pregnancy outcome.

CONCLUSION

Contraceptive use, especially of the most effective methods, remains low for adolescent women by 6 months post pregnancy.

Influences on birth spacing intentions and desired interventions among women who have experienced a poor obstetric outcome in Lilongwe Malawi: a qualitative study

BACKGROUND

Stillbirth and neonatal mortality are very high in many low-income countries, including Malawi. Use of family planning to encourage birth spacing may optimize outcomes for subsequent pregnancies. However, reproductive desires and influences on birth spacing preferences of women who have experienced a stillbirth or neonatal death in low-resource settings are not well understood.

METHODS

We conducted a qualitative study using 20 in-depth interviews and four focus group discussions with women who had experienced a stillborn baby or early neonatal death to explore attitudes surrounding birth spacing and potential interventions to promote family planning in this population. Qualitative data were analyzed for recurrent patterns and themes and central ideas were extracted to identify their core meanings.

RESULTS

Forty-six women participated in the study. After experiencing a stillbirth or neonatal death, most women wanted to wait to become pregnant again but women with living children wished to wait for longer periods of time than those with no living children. Most women preferred birth spacing interventions led by clinical providers and inclusion of their spouses.

CONCLUSIONS

Many influences on family size and birth spacing were noted in this population, with the most significant influencing factor being the spouse. Interventions to promote birth spacing and improve maternal and neonatal health in this population need to involve male partners and knowledgeable health care providers to be effective.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02674542 Registered February 1, 2016 (retrospectively registered).

Pregnancy after periviable birth: making the case for innovative delivery of interpregnancy care

Objective: Women who have had a spontaneous periviable delivery are at high risk for recurrent preterm delivery. The objective of our study was to determine interpregnancy interval (IPI) after periviable birth as well as percentage of women taking 17 alpha hydroxyprogesteronecaproate (17OHP-C) after periviable birth. We then examined the association between adherence with a postpartum visit after a periviable birth and IPI as well as receipt of 17OHP-C. Materials and methods: We included all women with a periviable delivery (20-26-week gestation) due to spontaneous preterm birth at Magee Women's Hospital between 2009 and 2014, who had their subsequent delivery at our institution during or before May of 2016. Information on maternal, fetal, and neonatal outcomes was obtained from the Magee Obstetrical Medical and Infant (MOMI) database as well as chart abstraction. We calculated IPI, proportion of women who received 17OHP-C in their next pregnancy, and attendance rates with a postpartum visit. The relationship between attendance with a postpartum visit and IPI, and receipt of 17OHP-C was examined with a logistic regression. Results: During the study period, 361 women had a spontaneous periviable birth. A total of 60 women had a subsequent delivery at Magee Women's Hospital. Only 33/60 (52.5%) presented for a postpartum visit after their periviable delivery. The median IPI for the cohort was 12.5 months (interquartile range: 6.4, 17.5 months) and 21.0% (n = 13) had an IPI less than 6 months. Adherence with the postpartum visit was not associated with an IPI less than 6 months. A total of 18.33% (11 women) did not receive 17OHP-C in their subsequent pregnancy. Women who attended a postpartum visit were much more likely to receive 17OHP-C (p = .001). Conclusions: Many women with a history of a periviable birth do not optimize strategies to reduce their risk of recurrent preterm birth. While attendance with a postpartum visit was associated with greater receipt of 17OHP-C in the subsequent pregnancy, given the overall poor rate of attendance with the postpartum visit in this cohort, novel strategies to counsel women about interpregnancy health are needed.

Disparities in Postpartum Contraceptive Counseling and Provision Among Mothers of Preterm Infants

OBJECTIVE

Use of effective contraception could be one method to decrease recurrent preterm birth by increasing intervals between pregnancies. We assessed correlates of contraceptive counseling and uptake among women who delivered preterm.

MATERIALS AND METHODS

This is a retrospective cohort study of women who delivered live-born singletons or twins before 32 weeks' gestation. We assessed documented contraceptive counseling and method uptake by postpartum discharge, using inpatient medical records, and correlates of highly effective contraception uptake by the postpartum visit using outpatient records.

RESULTS

Of 594 eligible women, 44.6% (n = 265) had documented inpatient contraceptive counseling, but only 21.4% (n = 127) left the hospital using a World Health Organization (WHO) tier 1 or 2 method. Women who were younger, non-Hispanic black, multiparous, and delivered at earlier gestational ages were more likely to have inpatient counseling documented. Compared with women with private insurance, women with public insurance were more likely to have documented counseling (22.8% vs. 87.5%, p < 0.001; adjusted odds ratio [aOR] 9.55, 95% confidence interval [CI] 5.31-17.2) and to uptake a WHO tier 1 or 2 method as an inpatient (5.8% vs. 52.0%, p < 0.001; aOR 9.51, 95% CI 4.78-18.9). Of the 175 women with outpatient records available who attended a postpartum visit, only 54.9% (n = 96) adopted a WHO tier 1 or tier 2 method.

CONCLUSION

Although all women in this cohort were at risk of recurrent preterm birth, counseling about contraception after a preterm birth (<32 weeks) was not universal. Women with multiple risk factors for recurrent preterm birth, such as multiparity and public insurance, were more likely to have received documented contraceptive counseling and highly effective contraceptives.

Interpregnancy Interval and Childbirth Outcomes in California, 2007-2009

Objectives The goals of interconception care are to optimize women's health and encourage adequate spacing between pregnancies. Our study calculated trends in interpregnancy interval (IPI) patterns and measured the association of differing intervals with birth outcomes in California. Methods Women with "non-first birth" deliveries in California hospitals from 2007 to 2009 were identified in a linked birth certificate and patient discharge dataset and divided into three IPI birth categories: <6, 6-17, and 18-50 months. Trends over the study period were tested using the Cochran-Armitage two-sided linear trend test. Chi square tests were used to test the association between IPI and patient characteristics and selected singleton adverse birth outcomes. Results Of 645,529 deliveries identified as non-first births, 5.6 % had an IPI <6 months, 33.1 % had an IPI of 6-17 months, and 61.3 % had an IPI of 18-50 months. The prevalence of IPI <6 months declined over the 3-year period (5.8 % in 2007 to 5.3 % in 2009, trend p value <0.0001).Women with an IPI <6 months had a significantly higher prevalence of early preterm birth (<34 weeks), low birthweight (<2500 g), neonatal complications, neonatal death and severe maternal complications than women with a 6-17 month or 18-50 month IPI (p < 0.005). Comparing those with a 6-17 month vs 18-50 month IPI, there were increased early preterm births and decreased maternal complications, complicated delivery, and stillbirth/intrauterine fetal deaths among those with a shorter IPI. Conclusions for Practice In California, women with an IPI <6 months were at increased risk for several birth outcomes, including composite morbidity measures.

Prevalence and Predictors of Prenatal and Postpartum Contraceptive Counseling in Two Texas Cities

OBJECTIVES

We investigated the prevalence of and sociodemographic associations with receiving prenatal and postpartum contraceptive counseling, including counseling on intrauterine devices (IUDs) and implants.

METHODS

We used data from a prospective cohort study of 803 postpartum women in El Paso and Austin, Texas. We examined the prevalence of prenatal and postpartum counseling, provider discouragement of IUDs and implants, and associated sociodemographic characteristics using χ2 tests and logistic regression.

RESULTS

One-half of participants had received any prenatal contraceptive counseling, and 13% and 37% received counseling on both IUDs and implants prenatally and postpartum, respectively. Women with more children were more likely to receive any contraceptive counseling prenatally (odds ratio [OR], 1.99; p < .01). Privately insured women (OR, 0.53; p < .05) had a lower odds of receiving prenatal counseling on IUDs and implants than publicly insured women. Higher education (OR, 2.16; p < .05) and attending a private practice (OR, 2.16; p < .05) were associated with receiving any postpartum counseling. Older age (OR, 0.61; p < .05) was negatively associated with receiving postpartum counseling about IUDs and implants and a family income of $10,000 to $19,000 (OR, 2.21; p < .01) was positively associated. Approximately 20% of women receiving prenatal counseling and 10% receiving postpartum counseling on IUDs and implants were discouraged from using them. The most common reason providers restricted use of these methods was inaccurate medical advice.

CONCLUSIONS

Prenatal and postpartum counseling, particularly about IUDs and implants, was infrequent and varied by sociodemographics. Providers should implement evidence-based prenatal and postpartum contraceptive counseling to ensure women can make informed choices and access their preferred method of postpartum contraception.

Racial and ethnic disparities in postpartum care and contraception in California's Medicaid program

BACKGROUND

Considerable racial and ethnic disparities have been identified in maternal and infant health in the United States, and access to postpartum care likely contributes to these disparities. Contraception is an important component of postpartum care that helps women and their families achieve optimal interpregnancy intervals and avoid rapid repeat pregnancies and preterm births. National quality measurements to assess postpartum contraception are being developed and piloted.

OBJECTIVE

To assess racial/ethnic variation in receipt of postpartum care and contraception among low-income women in California.

STUDY DESIGN

We conducted a prospective cohort study of 199,860 Californian women aged 15-44 with a Medicaid-funded delivery in 2012. We examined racial/ethnic variation of postpartum care and contraception using multivariable logistic regression to control for maternal age, language, cesarean delivery, Medicaid program, and residence in a primary care shortage area (PCSA).

RESULTS

Only one-half of mothers attended a postpartum visit (49.4%) or received contraception (47.5%). Compared with white women, black women attended postpartum visits less often (adjusted odds ratio [aOR], 0.73; 95% confidence interval [CI], 0.71-0.76), were less likely to receive any contraception (aOR, 0.83; 95% CI, 0.78-0.89) and were less likely to receive highly effective contraception (aOR, 0.64; 95% CI, 0.58-0.71). Women with Spanish as their primary language were more likely to get any contraception (aOR, 1.15; 95% CI, 1.11-1.19) but had significantly lower odds of receiving a highly effective method (aOR, 0.94; 95% CI, 0.90-0.99) compared with women with English as their primary language. Similarly, women in PCSAs had a greater odds of getting any contraception (aOR, 1.06; 95% CI, 1.03-1.09), but 24% lower odds of getting highly effective contraception than women not living in PCSAs (aOR, 0.76; 95% CI, 0.73-0.79).

CONCLUSION

Significant racial/ethnic disparities exist among low-income Californian mothers' likelihood of attending postpartum visits and receiving postpartum contraception as well as receiving highly effective contraception.

Determinants of contraceptive use among postpartum women in a county hospital in rural KENYA

Background

There is a high unmet need for limiting and spacing child births during the postpartum period. Given the consequences of closely spaced births, and the benefits of longer pregnancy intervals, targeted activities are needed to reach this population of postpartum women. Our objective was to establish the determinants of contraceptive uptake among postpartum women in a county referral hospital in rural Kenya.

Methods

Sample was taken based on a mixed method approach that included both quantitative and qualitative methods of data collection. Postpartum women who had brought their children for the second dose of measles vaccine between 18 and 24 months were sampled Participants were interviewed using structured questionnaires, data was collected about their socio-demographic characteristics, fertility, knowledge, use, and access to contraceptives. Chi square tests were used to determine the relationship between uptake of postpartum family planning and: socio demographic characteristics, contraceptive knowledge, use access and fertility. Qualitative data collection included focus group discussions (FDGs) with mothers and in-depth interviews with service providers Information was obtained from mothers’ regarding their perceptions on family planning methods, use, availability, access and barriers to uptake and key informants’ views on family planning counseling practices and barriers to uptake of family planning

Results

More than three quarters (86.3%) of women used contraceptives within 1 year of delivery, with government facilities being the most common source. There was a significant association (p ≤ 0.05) between uptake of postpartum family planning and lower age, being married, higher education level, being employed and getting contraceptives at a health facility. One third of women expressing no intention of having additional children were not on contraceptives. In focus group discussions women perceived that the quality of services offered at the public facilities was relatively good because they felt that they were adequately counseled, as opposed to local chemist shops where they perceived the staff was not experienced.

Conclusion

Contraceptive uptake was high among postpartum women, who desired to procure contraceptives at health facilities. However, there was unmet need for contraceptives among women who desired no more children. Government health facility stock outs represent a missed opportunity to get family planning methods, especially long acting reversible contraceptives, to postpartum women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4510-6) contains supplementary material, which is available to authorized users.