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Carranco S, Bohac S, Casey S, Sangi-Haghpeykar H, Conrad S. A survey of contraceptive method use among patients with delayed permanent contraception due to the COVID-19 pandemic. Contraception 2024; 132:110369. [PMID: 38224828 DOI: 10.1016/j.contraception.2024.110369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Abstract
OBJECTIVES Evaluate contraception usage in patients awaiting permanent contraception during COVID-19 pandemic. STUDY DESIGN Patients awaiting permanent contraception between March 2020 and July 2022 completed a survey assessing contraceptive usage. Descriptive statistics were analyzed. RESULTS One hundred and twenty-three patients consented to the survey. Ninety seven percent identified as Black, Indigenous, and people of color. Eighty three percent used alternative forms of contraception, with 31% using long acting, reversible contraceptives. Eighty nine percent still desired surgery. CONCLUSIONS Despite delays, most patients still desired surgery. Patients alternatively chose intrauterine devices and implants. IMPLICATIONS Hospitals should prioritize permanent contraception to avoid delays in access to desired reproductive healthcare options.
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Affiliation(s)
- Sara Carranco
- Baylor College of Medicine, Department of Obstetrics and Gynecology, Houston, TX, USA.
| | - Sarah Bohac
- Baylor College of Medicine, Department of Obstetrics and Gynecology, Houston, TX, USA
| | - Sarah Casey
- Baylor College of Medicine, Department of Obstetrics and Gynecology, Houston, TX, USA
| | | | - Sarah Conrad
- Baylor College of Medicine, Department of Obstetrics and Gynecology, Houston, TX, USA
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2
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Gelsinger C, Palmsten K, Lipkind HS, Pfeiffer M, Ackerman-Banks C, Hutcheon JA, Ahrens KA. Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine. Public Health Rep 2023:333549231170198. [PMID: 37129355 DOI: 10.1177/00333549231170198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE Preliminary findings from selected health systems revealed interruptions in reproductive health care services due to the COVID-19 pandemic. We estimated changes in postpartum contraceptive provision associated with the start of the COVID-19 pandemic in Maine. METHODS We used the Maine Health Data Organization's All Payer Claims Database for deliveries from October 2015 through March 2021 (n = 45 916). Using an interrupted time-series analysis design, we estimated changes in provision rates of long-acting reversible contraception (LARC), permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic. We performed 6- and 12-month analyses (April 2020-September 2020, April 2020-March 2021) as compared with the reference period (October 2015-March 2020). We used Poisson regression models to calculate level-change rate ratios (RRs) and 95% CIs. RESULTS The 6-month analysis found that provision of LARC (RR = 1.89; 95% CI, 1.76-2.02) and moderately effective contraception (RR = 1.51; 95% CI, 1.33-1.72) within 3 days of delivery increased at the start of the COVID-19 pandemic, while provision of LARC (RR = 0.95; 95% CI, 0.93-0.97) and moderately effective contraception (RR = 1.08; 95% CI, 1.05-1.11) within 60 days of delivery was stable. Rates of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased. RRs from the 12-month analysis were generally attenuated. CONCLUSION Disruptions in postpartum provision of permanent contraception occurred at the beginning of the COVID-19 pandemic in Maine. Public health policies should include guidance for contraceptive provision during public health emergencies and consider designating permanent contraception as a nonelective procedure.
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Affiliation(s)
- Catherine Gelsinger
- Muskie School of Public Service, University of Southern Maine, Portland, ME, USA
| | - Kristin Palmsten
- Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, MN, USA
| | - Heather S Lipkind
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Mariah Pfeiffer
- Muskie School of Public Service, University of Southern Maine, Portland, ME, USA
| | | | - Jennifer A Hutcheon
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, BC, Canada
| | - Katherine A Ahrens
- Muskie School of Public Service, University of Southern Maine, Portland, ME, USA
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3
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Stifani BM, Madden T, Micks E, Moayedi G, Tarleton J, Benson LS. Society of Family Planning Clinical Recommendations: Contraceptive Care in the Context of Pandemic Response. Contraception 2022; 113:1-12. [PMID: 35594989 PMCID: PMC9113767 DOI: 10.1016/j.contraception.2022.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 12/16/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has posed a burden to healthcare systems around the world and has changed the way people access health services, including contraception. This document sets forth guidance from the Society of Family Planning for providing contraceptive care in the context of the COVID-19 pandemic, including when access to healthcare is restricted due to pandemic response. It also outlines the role of telehealth for providing contraceptive care beyond the pandemic. Clinicians can use synchronous telemedicine visits and other forms of telehealth to provide many aspects of contraceptive care. Both audio-video and audio-only visits are acceptable forms of telemedicine. Access to permanent contraception should be maintained, especially in the postpartum period. Combined hormonal contraceptive (CHC) users who have asymptomatic or mild COVID-19 infection may continue their contraceptive method, while those admitted to the hospital with severe infection should suspend CHC use until they are clinically recovered. CHC users who take Paxlovid for mild-moderate COVID-19 infection can consider a back-up contraceptive method for the duration of therapy, but clinically relevant drug interactions are unlikely. Future research should examine contraceptive outcomes in people who receive care via telemedicine; and access to telemedicine among historically excluded populations such as adolescents, people of color, people of low socioeconomic status, disabled people, or people who do not speak English as a primary language.
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Affiliation(s)
- Bianca M. Stifani
- New York Medical College, Valhalla, NY, USA,Corresponding Author: Bianca M. Stifani, 19 Bradhurst Ave Suite 2700S, Hawthorne, NY, USA
| | - Tessa Madden
- Washington University School of Medicine, St Louis, MO, USA
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4
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Tomori C, Penta B, Richman R. Centering the Right to Health of Childbearing People in the US During the COVID-19 Pandemic. Front Public Health 2022; 10:862454. [PMID: 35719640 PMCID: PMC9201686 DOI: 10.3389/fpubh.2022.862454] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
Childbearing people in the US have experienced the double burden of increased risks from infection and significant disruptions to access and quality of essential health care services during the COVID pandemic. A single person could face multiple impacts across the course of their reproductive trajectory. We highlight how failure to prioritize this population in the COVID-19 policy response have led to profound disruptions from contraception services to vaccination access, which violate foundational principles of public health, human rights and perpetuate inequities. These disruptions continued through the omicron surge, during which many health systems became overwhelmed and re-imposed earlier restrictions. We argue that an integrated pandemic response that prioritizes the healthcare needs and rights of childbearing people must be implemented to avoid deepening inequities in this and future pandemics.
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Affiliation(s)
- Cecília Tomori
- Johns Hopkins University School of Nursing, Johns Hopkins University, Baltimore, MD, United States.,Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Bhavana Penta
- Johns Hopkins University School of Nursing, Johns Hopkins University, Baltimore, MD, United States
| | - Rebecca Richman
- Johns Hopkins University School of Nursing, Johns Hopkins University, Baltimore, MD, United States.,Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
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5
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Fang NZ, Advaney SP, Castaño PM, Davis A, Westhoff CL. Female permanent contraception trends and updates. Am J Obstet Gynecol 2022; 226:773-780. [PMID: 34973178 DOI: 10.1016/j.ajog.2021.12.261] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/02/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022]
Abstract
Permanent contraception remains one of the most popular methods of contraception worldwide. This article has reviewed recent literature related to demographic characteristics of users, prevalence of use and trends over time, surgical techniques, and barriers to obtain the procedure. We have emphasized the patient's perspective as a key element of choosing permanent contraception. This review has incorporated sections on salpingectomy, hysteroscopy, unmet need, impact of policies at religiously affiliated institutions, and reproductive coercion.
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Affiliation(s)
- Nancy Z Fang
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY; Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Center, Aurora, CO.
| | - Simone P Advaney
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Paula M Castaño
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Anne Davis
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
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6
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Russell CB, Qasba N, Evans ML, Frankel A, Arora KS. Variation in the interpretation and application of the Medicaid sterilization consent form among Medicaid officials. Contraception 2022; 109:57-61. [PMID: 35038447 PMCID: PMC9403908 DOI: 10.1016/j.contraception.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/01/2022] [Accepted: 01/07/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Medicaid consent policy has been identified as a major barrier to desired permanent contraception, particularly for low-income communities and communities of color. As each state may modify their state Medicaid sterilization consent form, variation in the form has been reported. This study aims to characterize state-level variation in Medicaid Title XIX consent form interpretation and application. STUDY DESIGN We aimed to collect primary data from Medicaid officials in all 50 United States from January to May 2020 via a 25-question electronic survey regarding state-level consent form implementation. Questions targeted consent form details and definitions, insurance and billing, clinician correspondence, and administrative processes. We used Qualtrics XM to collect survey responses. We performed descriptive statistics on the survey responses. There were no exclusion criteria. RESULTS We had 41 responses from 36/50 states (72% participation rate). Heterogeneity existed in the key definitions of "Premature Delivery" and "Emergency Abdominal Surgery." One in five respondents reported the consent form was only available in English. Variation among Current Procedural Terminology codes covered in each state's sterilization policy were noted. Nearly a quarter of respondents did not know how Medicaid informed healthcare providers of consent form denials. Most participants (90%) were unaware of differences between state sterilization policies. CONCLUSION This study demonstrates variation in terms of consent form definitions, procedures covered, correspondence with clinicians, and administrative review processes among state Medicaid offices regarding the sterilization consent form. Greater transparency is necessary in order to reduce administrative barriers to desired permanent contraception. IMPLICATIONS Inconsistent interpretation poses an administrative barrier to care, raises concern regarding appropriate clinician reimbursement, and can potentially lead to unnecessarily denying patients the contraceptive option of their choice. Permanent contraception policies should be equitable no matter insurance status, preserve reproductive autonomy and effectively protect vulnerable populations.
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Affiliation(s)
- Colin B Russell
- University of Michigan, Department of Obstetrics and Gynecology, Ann Arbor, MI, United States; Tufts University School of Medicine, Boston, MA, United States.
| | - Neena Qasba
- University of Massachusetts Medical School-Baystate Medical Center, Department of Obstetrics and Gynecology, Springfield, MA, United States
| | - Megan L Evans
- Tufts Medical Center, Department of Obstetrics and Gynecology, Boston, MA, United States
| | - Angela Frankel
- Tufts University School of Medicine, Boston, MA, United States
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland OH, United States; Department of Bioethics - Case Western Reserve University, Biomedical Research Building, Cleveland, OH, United States
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7
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Henkel A, Beshar I, Goldthwaite LM. Postpartum permanent contraception: updates on policy and access. Curr Opin Obstet Gynecol 2021; 33:445-452. [PMID: 34534995 DOI: 10.1097/gco.0000000000000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe barriers to provision of postpartum permanent contraception at patient, hospital, and insurance levels. RECENT FINDINGS Permanent contraception remains the most commonly used form of contraception in the United States with the majority of procedures performed during birth-hospitalization. Many people live in regions with a high Catholic hospital market share where individual contraceptive plans may be refused based on religious doctrine. Obesity should not preclude an individual from receiving a postpartum tubal ligation as recent studies find that operative time is clinically similar with no increased risk of complications in obese compared with nonobese people. The largest barrier to provision of permanent contraception remains the federally mandated consent for sterilization for those with Medicaid insurance. State variation in enforcement of the Medicaid policy additionally contributes to unequal access and physician reimbursement. Although significant barriers exist in policy that will take time to improve, hospital-based interventions, such as listing postpartum tubal ligation as an 'urgent' procedure or scheduling interval laparoscopic salpingectomy prior to birth-hospitalization discharge can make a significant impact in actualization of desired permanent contraception for patients. SUMMARY Unfulfilled requests for permanent contraception result in higher rates of unintended pregnancies, loss of self-efficacy, and higher costs. Hospital and federal policy should protect vulnerable populations while not preventing provision of desired contraception.
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Affiliation(s)
- Andrea Henkel
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, California, USA
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8
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Steenland MW, Geiger CK, Chen L, Rokicki S, Gourevitch RA, Sinaiko AD, Cohen JL. Declines in contraceptive visits in the United States during the COVID-19 pandemic. Contraception 2021; 104:593-599. [PMID: 34400152 PMCID: PMC8570647 DOI: 10.1016/j.contraception.2021.08.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/02/2021] [Accepted: 08/07/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To document the change in contraceptive visits in the United States during the COVID-19 pandemic. STUDY DESIGN Using a nationwide sample of claims we analyzed the immediate and sustained changes in contraceptive visits during the pandemic by calculating the percentage change in number of visits between May 2019 and April 2020 and between December 2019 and December 2020, respectively. We examined these changes by contraceptive method, region, age, and use of telehealth, and separately for postpartum individuals. RESULTS Relative to May 2019, in April 2020, visits for tubal ligation declined by 65% (95% CI, -65.5, -64.1), LARCs by 46% (95% CI, -47.0, -45.6), pill, patch, or ring by 45% (95% CI, -45.8, -44.5), and injectables by 16% (95% CI -17.2, -15.4). The sustained change in visits in December 2020 was larger for tubal ligation (-18%, 95% CI, -19.1, -16.8) and injectable (-11%, 95% CI, -11.4, -9.6) visits than for LARC (-6%, 95% CI, -6.6, -4.4) and pill, patch, and ring (-5%, 95% CI, -5.7, -3.7) visits. The immediate decline was highest in the Northeast and Midwest regions. Declines among postpartum individuals were smaller but still substantial. CONCLUSIONS There were large declines in contraceptive visits at the start of the COVID-19 pandemic and visit numbers remained below pre-pandemic levels through the end of 2020. IMPLICATIONS Declines in contraceptive visits during the pandemic suggest that many people faced difficulties accessing this essential health service during the COVID-19 pandemic.
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Affiliation(s)
- Maria W. Steenland
- Population Studies and Training Center, Brown University, Providence, RI, United States,Corresponding author
| | - Caroline K. Geiger
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, United States
| | - Lucy Chen
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, United States
| | - Slawa Rokicki
- Department of Health Behavior, Society, & Policy, Rutgers School of Public Health, Piscataway, NJ, United States
| | - Rebecca A. Gourevitch
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, United States
| | - Anna D. Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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9
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Potter JE, Burke KL, Broussard K, Hopkins K, Grossman D, White K. Improving assessment of demand for postpartum tubal ligation among publicly insured women in Texas. Contraception 2021; 104:518-523. [PMID: 34048752 PMCID: PMC10348345 DOI: 10.1016/j.contraception.2021.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess an alternative method for estimating demand for postpartum tubal ligation and evaluate reproductive trajectories of low-income women who did not obtain a desired procedure. STUDY DESIGN In a 2-year cohort study of 1700 publicly insured women who delivered at 8 hospitals in Texas, we identified those who had an unmet demand for tubal ligation prior to discharge from the hospital. We classified unmet demand as explicit or prompted based on survey questions that included a prompt regarding whether the respondent would like to have had a tubal ligation at the time of delivery. We assessed persistence of demand for permanent contraception, contraceptive use, and repeat pregnancies among all study participants who wanted but did not get a postpartum procedure. RESULTS Some 426 women desired a postpartum tubal ligation; 219 (51%) obtained one prior to discharge. Among the 207 participants with unmet demand, 62 (30%) expressed an explicit preference for the procedure, while 145 (70%) were identified from the prompt. Most with unmet demand still wanted permanent contraception 3 months after delivery (156/184), but only 23 had obtained interval procedures. By 18 months, the probability of a woman with unmet demand conceiving a pregnancy that she would likely carry to term was 12.5% (95% CI: 8.3%-18.5%). CONCLUSIONS The majority of unmet demand for postpartum tubal ligation among publicly insured women in Texas was uncovered via a prompt and would not have been evident in clinical records or from consent forms. Women unable to obtain a desired procedure had a substantial chance of pregnancy within 18 months after delivery. IMPLICATIONS Estimates of unmet demand for postpartum tubal ligation based on clinical records and consent forms likely underestimate desire for permanent contraception. Among low-income women in Texas, those with unmet demand for postpartum tubal ligation require improved access to effective contraception.
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Affiliation(s)
- Joseph E Potter
- Population Research Center, University of Texas, Austin, TX, United States.
| | - Kristen L Burke
- Population Research Center, University of Texas, Austin, TX, United States
| | - Kathleen Broussard
- Population Research Center, University of Texas, Austin, TX, United States
| | - Kristine Hopkins
- Population Research Center, University of Texas, Austin, TX, United States
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San, Francisco, Oakland, CA, United States
| | - Kari White
- Population Research Center, University of Texas, Austin, TX, United States
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Miller HE, Henkel A, Leonard SA, Miller SE, Tran L, Bianco K, Shaw KA. The impact of the COVID-19 pandemic on postpartum contraception planning. Am J Obstet Gynecol MFM 2021; 3:100412. [PMID: 34058421 PMCID: PMC8161810 DOI: 10.1016/j.ajogmf.2021.100412] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/10/2021] [Accepted: 05/26/2021] [Indexed: 12/02/2022]
Abstract
OBJECTIVE The COVID-19 pandemic necessitated rapid adjustment of obstetrical delivery models including fewer antenatal appointments and increased use of telehealth. We hypothesized that an increase in telemedicine and a decrease in antepartum visits owing to the COVID-19 pandemic led to a decreased proportion of people with a postpartum contraception plan at the time of the birth-hospitalization admission and a reduced uptake of top-tier forms of contraception at birth-hospitalization admission and discharge, and the routine postpartum visit, which has otherwise been increasing in recent years.1,2 STUDY DESIGN A retrospective cohort study comparing a randomly selected sample of people giving birth at a large, tertiary referral center during a regional “shelter in place” order, March 16, 2020, to July 31, 2020, with a previously abstracted random sample of people delivering between November 1, 2017, and April 30, 2018, was conducted. This study was reviewed and approved by the Stanford University Institutional Review Board before its initiation. The study was powered to detect a 10% difference in the proportion of those arriving at birth-hospitalization with a contraceptive plan (power 80%, alpha 0.05). The final sample size included 586 people (318 in the pre-COVID cohort and 268 in the COVID cohort). Multivariable modified Poisson regression model was used to estimate the relative risk of arriving at birth-hospitalization with a contraceptive plan in pre-COVID vs COVID cohorts, adjusting for age, parity, insurance status, and delivery mode. Secondary outcomes included tier of contraception plan at admission, discharge, and 6 weeks postpartum (classified by World Health Organization Tiered-Effectiveness3), attendance at postpartum visit, and whether the postpartum visit was conducted via telehealth. Tiered effectiveness was used for this study's purposes because it was hypothesized that telehealth would mostly affect the provision of top-tier forms of contraception that require in-person initiation. Fisher exact test was used to compare the secondary outcomes. RESULTS For the 2 cohorts, the median age was 32 years (range, 17–48 years) and median parity was 1 (range, 0–6). The majority (78%) had private insurance and most commonly identified as non-Hispanic White (38%) and Asian (36%). Baseline demographics did not differ between the cohorts. At birth-hospitalization admission, a smaller proportion of people had a postpartum contraceptive plan in the COVID cohort than in the pre-COVID cohort (73.9% vs 99.4%, adjusted risk ratio, 0.87; 95% confidence interval, 0.84–0.91, P<.001). A smaller proportion of people had a plan for top-tier contraception among the COVID cohort compared with the pre-COVID cohort at both admission and discharge (46.0% vs 71.0%, P<.01 and 31.0% vs 37.9%, P=.05) (Figure). More than 80% of the people attended a routine postpartum visit in both cohorts (P=.30) with 17.7% being telehealth visits in the COVID cohort compared with telehealth not being offered pre-COVID. Among those who attended their postpartum visit, the proportion discharged with a plan for interval top-tier contraception that was fulfilled was high in both groups (76.3% pre-COVID vs 71.2% post-COVID, P=.56). CONCLUSION The study found a significant decrease in people arriving at birth-hospitalization with a contraception plan in the months following a COVID-19 “shelter in place” order when compared with the pre-COVID cohort. It is suspected that changes in the obstetrical service models indirectly deprioritized the most effective forms of postpartum contraception because sterilization requires a signed consent before birth-hospitalization and postplacental intrauterine devices require consent before delivery.4,5 Current state legislation requiring in-person signature to consent for federally funded sterilization remains a barrier. We found that fewer individuals left with top-tier contraception than with plan on admission, especially within the COVID cohort. In addition to clinical contraindications that arise during labor, which preclude placement of an intrauterine device in the postpartum setting, many patients requested an expedited discharge during the peak of the COVID-19 pandemic. As the prenatal care model continues, this transition to adopt virtual visits, reduce visit schedules, and expedite postpartum discharge, actualizing patients’ contraceptive plans is increasingly more dependent on early inpatient provision. Maternity care providers should consider initiating postpartum contraception counseling and completing mandatory consents earlier in the antenatal period. This study is inherently limited by its retrospective nature of review and additional qualitative studies may better characterize this trend in contraceptive uptake. In the meantime, obstetrical care providers should carefully evaluate institutional barriers to postpartum contraception during this movement to telehealth.
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Affiliation(s)
- Hayley E Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, 300 Pasteur Dr. HH333, Stanford, CA 94305.
| | - Andrea Henkel
- Division of Family Planning Services and Research, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Stephanie A Leonard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Sarah E Miller
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Linh Tran
- Department of Obstetrics and Gynecology Stanford University School of Medicine San Mateo County Medical Center Stanford, CA
| | | | - Kate A Shaw
- Division of Family Planning Services and Research, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
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11
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Burke KL, Thaxton L, Potter JE. Short-acting hormonal contraceptive continuation among low-income postpartum women in Texas. Contracept X 2020; 3:100052. [PMID: 33490950 PMCID: PMC7809391 DOI: 10.1016/j.conx.2020.100052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/18/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The objective was to assess continuation of the pill, patch, ring or injectable (i.e., short-acting hormonal contraception); characteristics associated with discontinuation; and subsequent method use among low-income postpartum women in Texas. STUDY DESIGN Using a 24-month cohort study of 1700 women who delivered in eight Texas hospitals and were uninsured or publicly insured at the time of delivery, we focused on 456 women who used short-acting hormonal contraception within 6 months after delivery. We classified this sample according to characteristics and method preference, and estimated rates of discontinuation and associated predictors using life tables and Cox models. We assessed reasons for discontinuation and subsequent contraceptive use among those who discontinued. RESULTS Roughly half used the pill and half used the injectable. One hundred seventy-eight (39%) expressed a baseline preference for the method they used, 162 (36%) preferred a long-acting reversible contraception method, and 41 (9%) preferred sterilization. After 1 year, 72% had discontinued [95% confidence interval (CI) 67.1-75.7]. Foreign-born Hispanic women were less likely to discontinue than U.S.-born Hispanics [adjusted hazard ratio (aHR), 0.65; 95% CI 0.50-0.84]. Those who wanted a more effective method (aHR, 1.44; 95% CI 1.12-1.85) and those who lost insurance coverage (aHR, 1.47; 95% CI 1.12-1.92) were more likely to discontinue. The most common reasons for discontinuation were side effects and access/cost. Of those who discontinued, 243 (68%) switched to a less effective or no method. Only 47 (13%) switched to their preferred method. CONCLUSIONS Short-acting hormonal contraceptive discontinuation is high in this population. Many switch to less effective methods after discontinuation despite preferring methods at least as effective as the pill, patch, ring or injectable. IMPLICATIONS Expanding contraceptive coverage in the 2 years after delivery should be a state and federal policy priority. In clinics, providers should discuss contraceptive preferences throughout pregnancy and the interpregnancy interval.
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Affiliation(s)
- Kristen Lagasse Burke
- Population Research Center, University of Texas at Austin, Austin, TX, USA
- Department of Sociology, University of Texas at Austin, Austin, TX, USA
| | - Lauren Thaxton
- Department of Sociology, University of Texas at Austin, Austin, TX, USA
- Dell Medical School, Department of Women's Health, University of Texas at Austin, Austin, TX, USA
| | - Joseph E. Potter
- Population Research Center, University of Texas at Austin, Austin, TX, USA
- Department of Sociology, University of Texas at Austin, Austin, TX, USA
- Dell Medical School, Department of Women's Health, University of Texas at Austin, Austin, TX, USA
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