Postpartum contraceptive use among adolescent mothers in seven states

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study

BACKGROUND

Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception in general, although it is unclear if there is impact on permanent contraception specifically. Thus, we aimed to investigate the association between initial timing for prenatal documentation of a contraceptive plan for permanent contraception and fulfillment of postpartum contraception for those receiving counseling.

METHODS

This is a planned secondary analysis of a multi-site cohort study of patients with documented desire for permanent contraception at the time of delivery at four hospitals located in Alabama, California, Illinois, and Ohio over a two-year study period. Our primary exposure was initial timing of documented plan for contraception (first, second, or third trimester, or during delivery hospitalization). We used univariate and multivariable logistic regression to analyze fulfillment of permanent contraception before hospital discharge, within 42 days of delivery, and within 365 days of delivery between patients with a documented plan for permanent contraception in the first or second trimester compared to the third trimester. Covariates included insurance status, age, parity, gestational age, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index.

RESULTS

Of the 3103 patients with a documented expressed desire for permanent contraception at the time of delivery, 2083 (69.1%) had a documented plan for postpartum permanent contraception prenatally. After adjusting for covariates, patients with initial documented plan for permanent contraception in the first or second trimester had a higher odds of fulfillment by discharge (aOR 1.57, 95% C.I 1.24-2.00), 42 days (aOR 1.51, 95% C.I 1.20-1.91), and 365 days (aOR 1.40, 95% C.I 1.11-1.75), compared to patients who had their first documented plan in the third trimester.

CONCLUSIONS

Patients who had a documented prenatal plan for permanent contraception in trimester one and two experienced higher likelihood of permanent contraception fulfillment compared to those with documentation in trimester three. Given the barriers to accessing permanent contraception, it is imperative that comprehensive, patient-centered counseling and documentation regarding future reproductive goals begin early prenatally.

Evaluation of contraceptive intentions among pregnant women in the third trimester: A cross-sectional study

This study aims to determine contraceptive intentions of pregnant women in the third trimester. This cross-sectional study was conducted at a training and research hospital in Mardin province between March 2023 and May 2023. In total, 253 pregnant women who had the ability to communicate in Turkish and agreed to participate were included in the study. Data were collected through face-to-face interviews using a survey and the Contraceptive Intent Questionnaire (CIQ). The average age of the participants was 28.87 ± 5.35 with 30.8% of them holding a secondary school degree. It was found that there was a statistically significant difference in terms of CIQ score between categories of the following descriptive variables: education level, husband's/partner's education level, fertility plan, receiving family planning counseling during pregnancy, and paying for the contraceptive methods used (P = .046, P = .013, P < .001, P = .008, and P < .001 respectively). It was determined that pregnant women who had not received family planning counseling during pregnancy and paid for the contraceptive method had higher contraception intention.

The effect of maternal educational status, antenatal care and resumption of menses on postpartum contraceptive use in Ethiopia: systematic review and meta-analysis

The postpartum period is a crucial starting point for the delivery of family planning services. To date, there are numerous primary studies in Ethiopia on postpartum contraceptive use and related factors. However, the results of key variables are inconsistent, making it difficult to use the results to advance the service dimensions of postpartum contraceptive use in the country. Therefore, this systematic review and meta-analysis was required to summarize this inconsistency and compile the best available evidence on the impact of maternal educational status, antenatal care and menstrual resumption on postpartum contraceptive use in Ethiopia. PubMed, Google Scholar, Scopus, Science Direct, and the repositories of online research institutes were searched. Data were extracted with Microsoft Excel and analyzed with the statistical software STATA (version 14). Data on the study area, design, population, sample size, and observed frequency were extracted using the Joanna Briggs Institute tool. To obtain the pooled effect size, a meta-analysis was performed using a weighted inverse variance random effects model. Cochran's Q X2 test, and I2 statistics were used to test for heterogeneity, estimate the total quantity, and measure the variability attributed to heterogeneity. A mixed-effects meta-regression analysis was performed to identify possible sources of heterogeneity. To examine publication bias, the Eggers regression test and the Beggs correlation test were used at a p-value threshold of 0.001. Of the 654 articles reviewed, 18 studies met the inclusion criteria and were included in this meta-analysis. Overall, the final analysis includes 11,263 study participants. In Ethiopia, postpartum contraceptive use correlated significantly with maternal educational status (OR = 3.121:95% CI 2.127-4.115), antenatal care follow-up (OR = 3.286; 95% CI 2.353-4.220), and return of the mother's menses (OR = 3.492; 95% CI 1.843-6.615). A uniform meta-regression was performed based on publication year (p = 0.821), sample size (p = 0.989), and city of residence (p = 0.104), which revealed that none of these factors are significant. The use of postpartum contraceptives was found to be better among mothers who are educated, attended antenatal appointments, and resumed their menstrual cycle. Based on our research, we strongly recommended that antenatal care use and maternal educational accessibility need to improve. For family planning professionals, removing barriers to menstruation resumption should be a key priority.

Novel Shared Decision-Making Tool Improves Contraceptive Screening and Right Care during Pregnancy in a Military Hospital: A Quality Improvement Report

INTRODUCTION

Unintended pregnancy rates in the military remain high compared with rates outside of the military in the United States (54%-60% vs 45%-50%, respectively). Contraceptive counseling in conjunction with shared decision-making is recommended to improve military unintended pregnancy rates. Best counseling practices and decision aids for contraceptive counseling are unknown in military and nonmilitary populations. Pregnancy may be an opportune time to complete contraceptive counseling because of regularly scheduled prenatal visits, and counseling during pregnancy is associated with higher postpartum contraception use. A quality initiative was implemented to improve contraceptive screening and counseling during pregnancy for servicewomen and nonservicewomen in a clinic setting.

PROCESS

The initiative included 4 patient-centered core interventions: a patient screening, a shared decision-making tool, a right care checklist, and a team engagement plan, across 4 rapid plan-do-study-act cycles.

OUTCOMES

Contraceptive screening rates and delivery of right care improved from 37% to 79% in the pregnant patients over 90 days; 81% of patients screened positive for contraception needs; 89% of patients made a same-day decision about their contraception plan after completing the tool; and 92% of patients had a contraception plan documented in the electronic health record by the health care provider prior to birth.

DISCUSSION

Results demonstrated that contraception screening rates and right care improved with initiative interventions for servicewomen and nonservicewomen. A novel shared decision-making tool presented 18 contraception methods, risks and benefits, and tiered effectiveness that aided the majority of patients in a same-day decision with high patient satisfaction. Provider counseling was also simplified without delay in clinic time. Contraceptive counseling completed with a shared decision-making tool may benefit military and civilian populations during pregnancy. Additional research is needed to examine the best time to conduct counseling during pregnancy and the long-term rates of contraceptive use or unplanned pregnancy following counseling events.

Postpartum Visit Attendance in the United States: A Systematic Review

INTRODUCTION

Adequate postpartum care, including the comprehensive postpartum visit, is critical for long-term maternal health and the reduction of maternal mortality, particularly for people who may lose insurance coverage postpartum. However, variation in previous estimates of postpartum visit attendance in the United States makes it difficult to assess rates of attendance and associated characteristics.

METHODS

We conducted a systematic review of estimates of postpartum visit attendance. We searched PubMed, CINAHL, PsycInfo, and Web of Science for articles published in English from 1995 to 2020 using search terms to capture postpartum visit attendance and use in the United States.

RESULTS

Eighty-eight studies were included in this analysis. Postpartum visit attendance rates varied substantially, from 24.9% to 96.5%, with a mean of 72.1%. Postpartum visit attendance rates were higher in studies using patient self-report than those using administrative data. The number of articles including an estimate of postpartum visit attendance increased considerably over the study period; the majority were published in 2015 or later.

CONCLUSIONS

Our findings suggest that increased systematic data collection efforts aligned with postpartum care guidelines and attention to postpartum visit attendance rates may help to target policies to improve maternal wellbeing. Most estimates indicate that a substantial proportion of women do not attend at least one postpartum visit, potentially contributing to maternal morbidity as well as preventing a smooth transition to future well-woman care. Estimates of current postpartum visit attendance are important for informing efforts that seek to increase postpartum visit attendance rates and to improve the quality of care.

Uptake of postpartum modern family planning and its associated factors among postpartum women in Ethiopia: A systematic review and meta-analysis

OBJECTIVE

This study aimed to estimate the pooled prevalence and factors associated with postpartum modern contraceptive use in Ethiopia.

DESIGN

Systematic Reviews and Meta-Analysis.

METHOD

PubMed, MEDLINE, EMBASE, Hinari, Google Scholar, direct Google search, African Journal Online (AJOL), an online repository, and gray kinds of literature were used for searching. This meta-analysis included eighteen cross-sectional studies. The quality appraisal criterion of the Joanna Briggs Institute (JBI) was employed to critically appraise papers. The I2 statistics were used to test heterogeneity and subgroup analysis was computed with the evidence of heterogeneity. The Egger test with funnel plot was used to investigate publication bias. The "generate" command in STATA was used to calculate the logarithm and standard error of the odds ratio (OR) for each included study. Then odds ratio (OR) with a 95% confidence interval (CI) was presented.

RESULT

Eighteen studies were included in the systematic review and meta-analysis. The pooled prevalence of modern postpartum family planning utilization among postnatal women in Ethiopia was 45.44% (95%CI: 31.47, 59.42).Prenatal family planning counseling (AOR = 3.80; 95%CI: 2.70, 5.34), postnatal care utilization (AOR = 3.07; 95%CI: 1.39, 6.77), spouse communication on family planning (AOR = 1.86; 95%CI:1.36,2.54), resumption of menses (AOR = 4.20; 95%CI: 2.95, 5.99), and resumption of sexual activity (AOR = 3.98; 95%CI: 2.34, 6.79) were associated factors to uptake modern postpartum family planning among postnatal women.

CONCLUSION

The pooled prevalence of postpartum modern contraceptive use was low. The most common factors significantly associated with postpartum modern contraceptive use were prenatal family planning counseling, postnatal care utilization, spouse communication on family planning, resumption of menses, and resumption of sexual activity were the commonest factors significantly associated with postpartum modern contraceptive use.

Feasibility, acceptability and sustainability of postpartum contraceptive implant provision by midwives in NSW public hospitals

BACKGROUND

Repeat pregnancy in the first year after a birth is common. Many of these conceptions are unintended and may be prevented by providing access to contraception in the immediate postpartum period. Midwives in the hospital setting could potentially play a greater role in improving postnatal contraception information and provision.

AIM

We sought to implement and examine the success of a program training hospital-based midwives in immediate postpartum implant insertion.

METHODS

This mixed methods study in two hospitals in New South Wales sought to explore the feasibility, acceptability and sustainability of a program that provided competency-based implant insertion training for midwives. The study documented training completion, implant insertion numbers and experience, and conducted end of study interviews with midwives and stakeholders.

FINDINGS

Twenty-seven midwives undertook training and inserted 265 implants during the study period. Interviews with 13 midwives and 11 stakeholders concluded the program to be feasible and acceptable with midwives reporting high satisfaction from their involvement. All interviewees felt that midwives were well placed to insert implants, and reported that challenges around workload and opportunities for practice were generally manageable. It was recognised that sustainability of the program would require supportive policy and regular insertion opportunities.

CONCLUSIONS

Midwives successfully upskilled in implant insertions and there was widespread support for the program with expectations it would be sustained. Provision of contraceptive information and implant insertion by midwives in the immediate postpartum period is likely to increase contraceptive choice and access for women and contribute to reducing rapid repeat pregnancies.

Early Resumption of Sexual Intercourse after First Childbirth and Unintended Pregnancy within Six Months

OBJECTIVE

We aimed to evaluate factors associated with early resumption of sexual intercourse after first childbirth and assess whether early intercourse is associated with unprotected intercourse, subsequent pregnancy, and unintended pregnancy over 6 months.

METHODS

This secondary analysis used data from the First Baby Study, a prospective study of women aged 18-35 years with singleton pregnancies who delivered at 76 hospitals in Pennsylvania. At 1 and 6 months postpartum, women were asked about intercourse and the use of birth control since childbirth. We compared women who resumed intercourse in the first month after childbirth (early resumption) with those who resumed intercourse later, via multivariable logistic regression models.

RESULTS

In our cohort, 261 of 2,643 women (9.9%) reported first intercourse within the first postpartum month (7-31 days). Women who resumed intercourse early were less educated, younger, and less likely to breastfeed, have had a perineal laceration, or have had an episiotomy than those who resumed intercourse later. In addition, they were more likely to have unprotected intercourse in at least one of the first 6 months after first childbirth (adjusted odds ratio [aOR], 2.33; 95% confidence interval [CI], 1.76-3.09); to be pregnant by 6 months postpartum (aOR, 3.03; 95% CI, 1.48-6.20); and to report that pregnancy as unintended (aOR, 3.32; 95% CI, 1.50-7.36).

CONCLUSIONS

Nearly 10% of women resumed intercourse in the first month after childbirth. Because early resumption of intercourse was associated with a greater likelihood of unprotected intercourse and unintended pregnancy within 6 months of first childbirth, clinicians should focus efforts on comprehensive family planning and contraception counseling beginning in the prenatal period.

Implementing Interconception Care in a Dyadic Adolescent Mother-Child Clinic

INTRODUCTION

The birth of a second child to an adolescent woman worsens the adverse medical, socioeconomic, educational, and parenting outcomes for the woman and her children. Despite the known high efficacy of long-acting reversible contraception (LARC), many postpartum adolescents use less effective or no contraception. Interconception care (ICC) focuses on modifying maternal risks between pregnancies and promoting healthy birth spacing to improve outcomes for women and children. Research shows that women regularly attend their child's health care visits even if they do not seek care for themselves between pregnancies. These visits present a potential opportunity for providers to educate women on available LARC options.

METHODS

In an adolescent mother-child clinic, demographic and ICC screening data were collected on women presenting for well child visits of children age 0-24 months. These data were analyzed using logistic regression models to identify independent predictors of LARC initiation and repeat pregnancy.

RESULTS

Mother-child dyads were screened an average of two times in the study period. Participants with only one visit were less likely to initiate LARC. Of the participants, 5.5% became pregnant again, with patients having only one ICC visit being slightly, but not significantly more likely. Hispanic ethnicity and having ≥ 2 visits were significant independent predictors of LARC initiation. The only independent predictor of repeat pregnancy was not initiating LARC.

CONCLUSIONS

This study suggests that optimal ICC may rely on consistent and frequent touch points with providers and not solely on the medical management during the interconception period, making it adaptable to a traditional pediatric medical home. Tying the worlds of pediatric and maternal healthcare is pivotal for successful ICC.

Opioid use disorder: Calling pharmacists to action for better preconception and pregnancy care

Opioid use disorder (OUD) in women of child-bearing potential is problematic in the United States. This has resulted in increasing risk for adverse maternal outcomes, neonatal abstinence syndrome, fetal and neonatal harm, prolonged hospitalizations, and increased health care costs. Pharmacists in all practice settings have opportunities to provide preconception and pregnancy care to prevent and manage OUD. Given pharmacists' scope of practice and expertise, key roles include assessing patients for OUD; mitigating exposure; educating patients regarding potential infant effects; recommending contraceptive methods and counseling on proper use; ensuring safe breastfeeding with concurrent medications; and linking patients to needed services. Through patient counseling, medication management, and harm reduction interventions, pharmacists can work to combat this public health crisis. To encourage increased uptake of pharmacists into these roles, more needs to be done to reimburse pharmacists for these important services and quantify their impact on patient and population health outcomes.

Contraceptive Use and Its Associated Factors among Women Who Gave Birth within 12 Months in Dubti Town, Pastoral Community, of Afar Region Northeast, Ethiopia

Introduction

Substantial numbers of women are not using contraceptives in their postpartum period and die due to avoidable causes related to birth complications. Contraceptives use within 12 months of childbirth has given less attention in Ethiopia. Thus, this study is aimed to assess contraceptive use and its associated factors among women who gave birth within 12 months in Dubti town, pastoral community of Afar region, Ethiopia.

Methods

A community-based cross-sectional study was conducted among 342 women in the Dubti town. A systematic random sampling technique was employed to identify and enroll women. Data were collected using a pretested, structured, and interviewer-administered questionnaire. Descriptive statistics were done, and logistic regression analysis was employed to identify the factors associated with contraceptive use. The statistical association was measured by odds ratio with a 95% confidence interval. p value < 0.05 was considered as statistically significant.

Results

In this study, 103 (30.1%) [95% CI: 25.4%, 35.1%] women have used contraceptives. Women who had secondary educational level (AOR = 3.53, 95% CI (1.68, 7.36), had antenatal care follow-up (AOR = 1.93, 95% CI (1.01, 3.69), and visited by health worker after delivery (AOR = 2.54, 95% CI (1.37, 4.68) were associated with increased odds of contraceptives use.

Conclusions

This study revealed that the prevalence of contraceptive use was low compared to the national recommended figure. Secondary educational level, having antenatal care follow-up, and being visited by health workers after delivery were predictors of contraceptive use. Thus, increase the educational status of women, antenatal care follow-up service, and visiting after delivery by health workers are important interventions to promote the use of contraceptives in the postpartum period.

Acceptability of immediate postpartum and post-abortion long-acting reversible contraception provision to adolescents: A systematic review

INTRODUCTION

Long-acting reversible contraception (LARC) methods are safe for adolescents and provide the greatest assurance against rapid repeated pregnancy when inserted during the immediate postpartum (IPP) and immediate post-abortion (IPA) period. Despite increasing enthusiasm for IPP/IPA LARC insertion, adolescents' preferences and experiences have seldom been examined. The objective of this review was to examine the attitudes of adolescents (aged 10-19 years) towards IPP/IPA LARC, their experiences and perceptions around having an LARC device fitted IPP/IPA and the factors involved in decision-making to use, not use or discontinue IPP/IPA LARC.

MATERIAL AND METHODS

In January 2021, we searched seven bibliographic databases for original research articles published in English, from the year 2000. Studies of any design focused on IPP/IPA LARC were eligible for inclusion. Three of the authors assessed articles for eligibility and extracted data relevant to the outcomes of the review. Joanna Briggs Institute Critical Appraisal Tools were used to assess methodological quality. Key themes emerging from the data were synthesized and reported narratively.

RESULTS

We identified 10 relevant articles, four of which were entirely adolescent-focused. Only three addressed IPA LARC. IPP availability was important for ensuring access to LARC postpartum. Attitudes towards LARC IPP were associated with adolescents' sociodemographic characteristics and positive perceptions related to the long duration of action. Determinants of discontinuation and nonuse included poor-quality contraceptive counseling, intolerable side effects and subsequent distress, misconceptions about LARC safety IPP and the influence of partners and community on autonomy. No factors involved in IPA LARC decision-making were available. Limited evidence demonstrated that adolescents may favor contraceptive implants over intrauterine devices, and in certain contexts may face greater barriers to IPA LARC access than adult women do.

CONCLUSIONS

Immediate insertion of LARC postpartum appears acceptable to adolescents who do not experience side effects and those with the opportunity to make autonomous contraception decisions. This important topic has been addressed in few studies involving an entirely adolescent population. Very limited evidence is available on IPA LARC. Further research on adolescents' lived experiences of IPP/IPA LARC access and use is necessary to inform the provision of person-centered care when assisting adolescents' contraceptive choice following pregnancy.

Contraception provision in the postpartum period: Knowledge, views and practices of midwives

BACKGROUND

Women are susceptible to unintended pregnancies in the first year after giving birth, particularly as consideration of contraception may be a low priority during this time. Discussing and providing contraception before women leave hospital after giving birth may prevent rapid repeat pregnancy and its associated risks. Midwives are well placed to assist with contraceptive decision-making and provision; however, this is not routinely undertaken by midwives in the Australian hospital setting and little is known regarding their views and experiences in relation to contraception.

METHODS

An anonymous survey was conducted with midwives at two urban hospitals in New South Wales to better understand their contraceptive knowledge, views and practices regarding midwifery-led contraception provision in the postpartum period.

FINDINGS

The survey was completed by 128 midwives. Most agreed that information about contraception provided in the postpartum period is valuable to women, although their knowledge about different methods was variable. The majority (88%) believed that midwives have a role in providing contraceptive information, and 79% reported currently providing contraceptive counselling. However, only 14% had received formal training in this area.

CONCLUSION

Findings demonstrate that most midwives provide some contraception information and believe this is an important part of a midwife's role. Yet most have not undertaken formal training in contraception. Additional research is needed to explore the content and quality of midwives' contraception discussions with women. Training midwives in contraceptive counselling would ensure women receive accurate information about available options. Upskilling midwives in contraception provision may increase postpartum uptake and reduce rapid repeat pregnancies.

Postpartum and post-abortion contraceptive use among unmarried young women in Ghana

Pregnancy outcomes impact subsequent contraceptive behaviour. The purpose of this study was to assess the relationship between previous pregnancy outcomes and subsequent contraceptive behaviours among unmarried young women intending to delay childbearing. Using data from the 2014 Ghana Demographic and Health Survey, among 1118 sexually experienced, fecund and non-pregnant unmarried women aged 15-24 years, the study assessed how childbirth and abortion are related to sexual abstinence and use of modern contraception. While about 70% of unmarried young women were nulligravid, approximately 11% had had an abortion and 18.2% were postpartum. The majority of respondents were sexually abstinent while 21% and 27% were using and not using contraception, respectively. Postpartum women were more likely than nulligravid and post-abortion women to use contraceptives. Post-abortion women were least likely to be sexually abstinent. Number of years since the respondent's sexual debut was positively associated with the likelihood of using modern contraception, particularly among postpartum women, and negatively associated with sexual abstinence among those who had aborted. The findings show that prior pregnancy outcomes have significant implications for secondary abstinence and contraceptive use among unmarried young women in Ghana. Post-abortion women are more likely than postpartum women to be sexually active but less likely to use contraceptives. Efforts must be strengthened towards increasing access to modern contraceptives for young women who present for abortion in Ghana.

Intentionally or Ambivalently Risking a Short Interpregnancy Interval: Reproductive-Readiness Factors in Women's Postpartum Non-Use of Contraception

A focus of research on short interpregnancy intervals (IPI) has been on young disadvantaged women whose births are likely to be unintended. Later initiation of family formation in the United States and other high-income countries points to the need to also consider a woman's attributes indicative of readiness for purposefully accelerated family formation achieved through short IPIs. We test for whether factors indicating "reproductive readiness"-including being married, being older, and having just had a first birth or a birth later than desired-predict a woman's non-use of contraception in the postpartum months. We also test for whether this contraceptive non-use results explicitly from wanting to become pregnant again. The data come from the 2012-2015 Pregnancy Risk Assessment Monitoring System, representing women who recently gave birth in any of 35 U.S. states and New York City (N = 120,111). We find that these reproductive-readiness factors are highly predictive of women's postpartum non-use of contraception because of a stated desire to become pregnant and are moderately predictive of contraceptive non-use without an explicit pregnancy intention. We conclude that planning for, or ambivalently risking, a short IPI is a frequent family-formation strategy for women whose family formation has been delayed. This is likely to become increasingly common as family formation in the United States is initiated later in the reproductive life course.

Informing Policy Change: A Study of Rapid Repeat Pregnancy in Adolescents to Increase Access to Immediate Postpartum Contraception

Background: Rapid repeat pregnancy (RRP) is common among adolescents and is associated with adverse maternal and infant outcomes. Despite evidence that use of long-acting forms of contraception before hospital discharge can help minimize RRP rates, barriers to placement existed within the state of Indiana. We sought to determine state-specific RRP and induced abortion rates for adolescents based on chosen postpartum contraception to inform policy change. Methods: We examined a retrospective cohort of 227 adolescents (ages 12-18 years) who gave birth in Indiana between 2010 and 2012. Demographics, postpartum contraception, and subsequent pregnancies or abortions after the sentinel delivery were obtained. Rates of RRP based on type of immediate postpartum contraception, etonogestrel (ENG) contraceptive implant, depo-medroxyprogesterone acetate (DMPA) injection, and short-acting methods were compared. Bivariate and logistic regression analyses were conducted. Results: RRP rates were 3.7% for those with ENG contraceptive implant, 22.6% for those with DMPA, and 39.1% for those who choose short-acting methods (p = 0.01). Adolescents who did not choose an ENG contraceptive implant were significantly more likely to have an RRP (adjusted odds ratio [aOR] = 11.8, 95% confidence interval: 2.74-110.3), compared with other contraceptive methods, even after adjusting for covariates such as age, prior pregnancies, and postpartum visit attendance. Conclusions: Immediate postpartum receipt of ENG implant was significantly associated with a lower likelihood of RRP in adolescents in Indiana. These data facilitated state policy change regarding insurance reimbursement to improve statewide access for all women, regardless of age, showing how local data can inform policy change.

Postpartum Contraceptive Use In Parakou (A City In Northern Benin) In 2018: A Community Based Cross-Sectional Study

Background

Over 30% of maternal deaths and 10% of infant deaths are avoidable if couples space out births at intervals of 2 years or greater. This study aimed to identify factors associated with contraceptive use in the postpartum period.

Methods

This was a cross-sectional study among postpartum women living in Parakou. Participants were selected using a two-stage sampling method. Postpartum contraceptive use was defined as the use of at least one contraceptive method at the time of the survey. Independent variables included socio demographic and reproductive history. For the analysis we performed a multiple logistic regression and we calculated odds ratios with 95% confidence intervals.

Results

The study included 453 postpartum women. Among the participants, 59 (13%) were using a contraceptive method. Injectable contraceptives were the most common method used (25.4%). Factors associated with contraceptive use in the postpartum period included history of contraceptive use (AOR=9.4; p<0.001), resumption of sexual intercourse (AOR=5.7; p<0.001), discussion with partner about contraceptive method (AOR=5.7; p=0.005), need of partner’s approval before adopting a contraceptive method (AOR=0.4; p=0.014) and counseling during pregnancy, in the delivery room, and during postnatal visits (AOR=2.7; p=0.019).

Conclusion

The prevalence of contraceptive use during the postpartum period remains low. Interventions should be designed with a focus on the associated factors in order to increase postpartum contraceptive use in Parakou.

Quality of postpartum contraceptive counseling and changes in contraceptive method preferences

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Exploring Indonesian adolescent women's healthcare needs as they transition to motherhood: A qualitative study

BACKGROUND

Marriage and underage childbirth is a phenomenon of increasing incidence globally. Adolescent mothers simultaneously encounter multiple developmental challenges related to transition into adulthood, marriage, pregnancy and mothering responsibilities. Despite this, studies investigating postpartum care needs for adolescent mothers are limited.

AIMS

The aim of this study was to explore adolescent mothers' postnatal inpatient experiences and healthcare needs as they moved towards their maternal roles.

METHODS

A descriptive qualitative design was adopted to better understand experiences of adolescent mothers during their transition to becoming mothers. Data were collected using in-depth interviews with eleven adolescent mothers in hospital settings in South Sulawesi, Indonesia and analysed using thematic analysis.

RESULTS

Four major themes emerged: (1) breastfeeding problems, (2) disempowerment in caring for the baby, (3) health care encounters, and (4) health care needs for adolescent motherhood transition.

DISCUSSION

Breastfeeding problems and feeling disempowered in caring for their babies after birth was experienced by all adolescent mothers in this study. Furthermore, the health care provided was limited to mandatory hospital tasks with staff failing to recognize adolescent mothers' broader needs. The findings suggest that adolescent mothers need compassionate health education, support and psychological care from midwives in the postpartum ward before hospital discharge.

CONCLUSION

The results highlight important issues in postnatal care provision for adolescent mothers in improving their maternal roles during the transition period. Specific, appropriate interventions for adolescent mothers are needed to support their transition and adaptation to their new roles.

Does Postpartum Contraceptive Use Vary By Birth Intendedness?

CONTEXT

Women with an unintended birth have an elevated risk of subsequent unintended pregnancy, and multiple unintended pregnancies could exacerbate any negative consequences of such births. It is therefore important to understand whether postpartum contraceptive use differs by birth intendedness.

METHODS

Data on 2,769 births reported in the 2011-2015 cycles of the National Survey of Family Growth were used to examine postpartum contraceptive use. Life-table estimates were employed to assess differences by birth intendedness in timing of postpartum contraceptive use, and multinomial logistic event history methods were used to model initial contraceptive uptake and efficacy by birth intendedness.

RESULTS

Compared with postpartum women whose births were on time or too late, those with seriously mistimed and those with unwanted births were more likely to first adopt a highly effective method (e.g., implant or IUD), rather than no method (relative risk ratios, 1.9 and 1.7, respectively); mothers with unwanted births were also more likely to first use least effective methods (e.g., condoms or withdrawal) instead of no method (1.5). Mothers with seriously mistimed births had a reduced likelihood of using either effective methods (e.g., the pill or injectable) or least effective methods, rather than highly effective ones (0.5 for each).

CONCLUSION

The elevated risk of repeat unintended fertility does not seem to be due to mothers' initial postpartum contraceptive behavior. Whether mothers with unintended births use contraceptives less consistently, discontinue use sooner or switch methods more often than those with intended births remains to be seen.

Predictors of postpartum contraceptive use in rural Tigray region, northern Ethiopia: a multilevel analysis

Background

Postpartum family planning services is one of the recommended public health intervention aimed at reducing maternal and child morbidity and mortalities. However, there is a paucity studies in rural Tigray region. Therefore, determining the level and associated factors of contraceptive use among postpartum women has the potential to contribute in achieving the Ethiopian Health Sector Transformation Plan and to the Sustainable Development Goals on maternal and infant survival.

Methods

A community-based cross-sectional study was done among 1109 postpartum women from March 29, 2017 to April 29, 2017. Face –to–face interview was used for data collection. The collected data were entered and cleaned using EPI - INFO version 7statistical software and later exported to and analyzed using STATA version 12. Mixed-effects multilevel logistic regression analysis was used to identify the individual and community-level factors associated with contraception adoption. A two side p-value< 0.05 was considered to be statistically significant.

Results

The level of contraceptive use was 38.3%. Individual-level variables such as women belong to fourth (AOR = 1.2; 95% CI: 1.1–3.2) and fifth (AOR = 1.5; 95% CI: 1.3–2.5) wealth quintiles were identified as key predictors of contraception use. In addition, partner secondary (AOR = 2.3; 95% CI: 1.8–3.5) and diploma (AOR = 1.2; 95% CI, 1.1–2.6) educational-level and postnatal care (AOR = 2.0; 95% CI: 1.9, 4.3) were also significantly affected contraception use. Community-level variables such as high community-level antenatal care services use (AOR = 2.1; 95% CI: 1.9–4.2) and proximity of women to health facility (AOR = 3.0; 95% CI: 2.7–4.6) were also determinants of contraception uptake.

Conclusions

The status of contraceptive use in rural Tigray region was found to be low. It was found that both individual and community-level variables showed a marked determinant on postpartum contraception use. This study suggested that in order to increase contraceptive use the government should focus on increasing postnatal care, antenatal care services use and reduction of poverty level are important avenues for intervention.

Correlates of sexual inactivity and met need for contraceptives among young women in Ghana

Background

Young women in sub-Saharan Africa continue to experience unintended pregnancies despite effective contraceptive methods being more readily available than ever. This study sought to determine the correlates of met need for contraceptives and sexual inactivity among young women in Ghana who want to postpone childbearing. We examine this among all women and then separately by marital status.

Methods

Using data from 1532 females aged 15–24 years from the 2014 Ghana Demographic and Health Survey, we conducted descriptive and multinomial logistic regression analyses to assess sociodemographic, economic and obstetric determinants of the type of family planning method (current abstinence, modern contraceptive method) used by married and unmarried young women.

Results

A higher proportion (~ 44%) of the respondents was currently abstinent compared to those with met need (~ 25%). Abstinence was higher among single young women while unmet and met need were higher among the married. Having at least senior high school education was significantly associated with the likelihood of current abstinence (especially among single women) and with met need. Being in the middle and rich categories, on the other hand, was associated with lower likelihood of current abstinence and a met need. Compared with multiparous women, those with one or no surviving child had a lower likelihood of being abstinent and having a met need. Other correlates of both current abstinence and met need are region of residence and ethnicity, while previous pregnancy termination and age were associated with abstinence and contraceptive use, respectively.

Conclusions

Unmet need is high among young women but abstinence is an option they are using. As reproductive health programmes target the at-risk groups, the secondary and higher educational levels must be attained by most women as this is associated with use of abstinence and met need.

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.

Health and Social Needs of Young Mothers

PURPOSE

Teen parenting rates are disproportionately high among minority youth in the Southern United States. We explored barriers and unmet needs relating to medical and social support as perceived by these teen mothers, and elicited suggestions for improving their healthcare through the medical home.

STUDY DESIGN AND METHODS

We conducted four focus groups of 18- to 24-year-old mothers in New Orleans with questions designed to prompt discussions on young motherhood and healthcare. All 18 participants identified as African American, became mothers when <20, and their children were <5 at the time of the study. Two researchers independently analyzed focus group transcripts and coded them thematically, revealing various unmet social and health needs.

RESULTS

Seven main themes emerged, which revealed a concerning lack of mental healthcare, few with consistent medical homes, inadequate contraceptive knowledge and access, and a desire for parenting education and support groups. Suggestions for improving care largely centered around logistical and material support, such as extended clinic hours, transportation, and baby supplies.

CLINICAL IMPLICATIONS

Findings suggest a need for improved medical knowledge, healthcare access, and social support for teen mothers. This may be provided through a multidisciplinary medical home model, such as a Teen-Tot clinic, where the unique challenges of adolescent parenting are continuously considered.

Postpartum Contraception and Interpregnancy Intervals Among Adolescent Mothers Accessing Public Services in California

Objective To determine the association of age at index birth with postpartum contraceptive use and optimal interpregnancy interval (IPI, defined as delivery to next pregnancy >18 months), controlling for provider type and client demographics among adolescent mothers who have repeat pregnancies. Methods California's 2008 birth records were linked to California's Medi-Cal and Family PACT claims data to identify 26,393 women with repeat births between 2002 and 2008, whose index birth occurred as an adolescent, and who received publicly-funded services within 18 months after the index birth. Multivariable regression analyses were conducted to examine the relationship between timing of contraception provision and interpregnancy intervals, adjusting for socio-demographic factors. Results Seventy-eight percent of adolescent women did not receive contraception at their first postpartum visit, and twenty-eight percent of adolescent women never received contraception from a Family PACT or Medi-Cal provider. Adolescents who were older at their index birth had lower rates of optimal IPIs. Native American, Asian-Pacific Islander and Latina women had lower rates of optimal IPIs compared to white women. Compared to those using only barrier methods, adolescent women receiving highly effective contraceptive methods had a 4.25 times higher odds of having an optimal IPI than those receiving hormonal methods (OR 2.10), or using no method (OR 0.70). Conclusion Effective postpartum contraceptive use and being a Family PACT provider were associated with optimal birth spacing among adolescent mothers, yet racial and ethnic disparities persisted. A missed opportunity was the provision of contraception at the first postpartum visit. Providers should aim to remove barriers to initiation of contraception at this visit.

Exploring young mothers' experiences with postpartum contraception in Ottawa: results from a multimethods qualitative study

OBJECTIVES

Postpartum contraception plays a significant role in reducing subsequent pregnancy. However, young mothers in Ottawa, the capital of Canada, face various barriers when trying to access contraception after delivery. Through this project, we aimed to explore these barriers and understand the decision-making processes of young mothers surrounding postpartum contraception.

STUDY DESIGN

We conducted 10 semistructured in-depth interviews with young mothers living in Ottawa who had experienced a subsequent pregnancy within 24months of their first childbirth. In addition, we interviewed 10 key informants who work with teenage mothers. We audio-recorded and transcribed all interviews and analyzed them using inductive and deductive techniques. We used ATLAS.ti software to manage our data.

RESULTS

Both young mothers and key informants report that teen mothers in Ottawa often do not use postpartum contraception or inconsistently use their chosen contraceptive method. Many factors, including cost, personal beliefs, personal priorities and knowledge, influence young mothers' decision making surrounding contraception.

CONCLUSIONS

Our study suggests that when young mothers do not use postpartum contraception, the reasons are complex; for some, this is a choice, and for others, this is the result of systems-level, service delivery and information barriers. Supporting policies to ensure that a full range of contraceptive methods are available and affordable and developing educational programs in Ottawa that are sex-positive and nonjudgmental appear warranted.

IMPLICATIONS

Ensuring that a full method mix, including contraceptive implants, is available to and affordable for young mothers in Ottawa could meet significant needs. Addressing existing systems-level, service delivery and information barriers through supporting evidence-based policies and sex-positive and nonjudgmental educational programs appears warranted.

Concordance between intention to use and current use of contraceptives among six-month postpartum women in Brazil: The role of unplanned pregnancy

OBJECTIVE

to examine the effect of pregnancy planning status in the concordance between intention to use and current use of contraceptives among postpartum women.

DESIGN AND SETTING

a prospective study was conducted in 12 primary health care facilities in São Paulo, Brazil, from November 2013 to September 2014.

PARTICIPANTS

A total of 264 woman aged 15-44 years old completed a face-to-face interview when they were pregnant (baseline), and were interviewed by phone at 6 months postpartum.

MEASUREMENTS

At baseline, participants were questioned about the contraceptive method they would prefer to be using at 6 months postpartum. At 6 months postpartum, they answered about the contraceptive method they were currently using. Pregnancy planning status was measured using the Brazilian Portuguese London Measure of Unplanned Pregnancy. We conducted logistic regression, considering contraceptive preference-use concordance as the dependent variable and the main covariate as pregnancy planning status.

FINDINGS

Only 28.9% of postpartum women were using the method they preferred to use when they were pregnant. The agreement between preference and contraceptive use was higher for injectables (60.9%) and lowest for IUD, as nobody who preferred it was actually using it. Women who were not sure about what method they intended to use after childbirth more frequently reported no use at six months postpartum. Multivariate logistic regression showed that postpartum women whose pregnancy was unplanned were less likely to use the contraceptive methods that they intended to use when they were pregnant [aOR=0.36; 95%CI=0.14-0.97].

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Brazilian women were able to access contraceptives in the postpartum period. However, there is a considerable discordance between their contraceptive intention to use and use at the sixth postpartum month. A higher unmet demand for IUD and sterilization should be highlighted. The pregnancy planning status is associated to postpartum contraceptive preference-use concordance, so interventions before pregnancy may affect postpartum contraceptive use. Women with unintended pregnancies present an important opportunity to offer additional family planning counseling.

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.

“It was kind of like if it happens it happens. It wasn’t planned, it wasn’t intentional”: Young mothers’ experiences with subsequent pregnancy in Ottawa, Canada

Young mothers constitute a vulnerable population in Canada. Teens with children are at significant risk of subsequent pregnancy, a dynamic that can exacerbate health, emotional, and socio-economic challenges. We aimed to understand better the dynamics shaping “rapid repeat pregnancy” among young mothers in Ottawa, explore young mothers’ subsequent pregnancy experiences, and identify how services could be improved in Canada’s capital. In 2016, we conducted in-depth interviews with 10 young mothers and semi-structured interviews with 10 key informants working with pregnant and parenting youth. We analyzed interviews for content and themes using a multi-phased, iterative process. Four major themes emerged: (1) young mothers often plan their pregnancies actively or passively; (2) violence before, during, and after pregnancy is common; (3) mental health and substance abuse issues shape pregnancy risk; and (4) becoming pregnant often serves as a source of motivation for young mothers. Our results further indicate that young mothers have difficulty finding youth-friendly, non-judgmental support services and that integrated, multidisciplinary services offering individually tailored support and building on women’s strengths will likely be more successful in helping young mothers prevent subsequent pregnancies. Increasing awareness about existing services and supporting efforts that approach teen pregnancy comprehensively and holistically appear warranted.

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

OBJECTIVE

To assess women's preferences for contraception after delivery and to compare use with preferences.

METHODS

In a prospective cohort study of women aged 18-44 years who wanted to delay childbearing for at least 2 years, we interviewed 1,700 participants from eight hospitals in Texas immediately postpartum and at 3 and 6 months after delivery. At 3 months, we assessed contraceptive preferences by asking what method women would like to be using at 6 months. We modeled preference for highly effective contraception and use given preference according to childbearing intentions using mixed-effects logistic regression testing for variability across hospitals and differences between those with and without immediate postpartum long-acting reversible contraception (LARC) provision.

RESULTS

Approximately 80% completed both the 3- and 6-month interviews (1,367/1,700). Overall, preferences exceeded use for both-LARC: 40.8% (n=547) compared with 21.9% (n=293) and sterilization: 36.1% (n=484) compared with 17.5% (n=235). In the mixed-effects logistic regression models, several demographic variables were associated with a preference for LARC among women who wanted more children, but there was no significant variability across hospitals. For women who wanted more children and had a LARC preference, use of LARC was higher in the hospital that offered immediate postpartum provision (P<.035) as it was for U.S.-born women (odds ratio [OR] 2.08, 95% CI 1.17-3.69) and women with public prenatal care providers (OR 2.04, 95% CI 1.13-3.69). In the models for those who wanted no more children, there was no significant variability in preferences for long-acting or permanent methods across hospitals. However, use given preference varied across hospitals (P<.001) and was lower for black women (OR 0.26, 95% CI 0.12-0.55) and higher for U.S.-born women (OR 2.32, 95% CI 1.36-3.96), those 30 years of age and older (OR 1.82, 95% CI 1.07-3.09), and those with public prenatal care providers (OR 2.04, 95% CI 1.18-3.51).

CONCLUSION

Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of health care provider and system-level barriers. Expansion of immediate postpartum LARC provision as well as contraceptive coverage for undocumented women could reduce the gap between preference and use.

Intervention Now to Eliminate Repeat Unintended Pregnancy in Teenagers (INTERUPT): a systematic review of intervention effectiveness and cost-effectiveness, and qualitative and realist synthesis of implementation factors and user engagement

BACKGROUND

Unintended repeat conceptions can result in emotional, psychological and educational harm to young women, often with enduring implications for their life chances. This study aimed to identify which young women are at the greatest risk of repeat unintended pregnancies; which interventions are effective and cost-effective; and what are the barriers to and facilitators for the uptake of these interventions.

METHODS

We conducted a mixed-methods systematic review which included meta-analysis, framework synthesis and application of realist principles, with stakeholder input and service user feedback to address this. We searched 20 electronic databases, including MEDLINE, Excerpta Medica database, Applied Social Sciences Index and Abstracts and Research Papers in Economics, to cover a broad range of health, social science, health economics and grey literature sources. Searches were conducted between May 2013 and June 2014 and updated in August 2015.

RESULTS

Twelve randomised controlled trials (RCTs), two quasi-RCTs, 10 qualitative studies and 53 other quantitative studies were identified. The RCTs evaluated psychosocial interventions and an emergency contraception programme. The primary outcome was repeat conception rate: the event rate was 132 of 308 (43%) in the intervention group versus 140 of 289 (48%) for the control group, with a non-significant risk ratio (RR) of 0.92 [95% confidence interval (CI) 0.78-1.08]. Four studies reported subsequent birth rates: 29 of 237 (12%) events for the intervention arm versus 46 out of 224 (21%) for the control arm, with an RR of 0.60 (95% CI 0.39-0.93). Many repeat conceptions occurred in the context of poverty, low expectations and aspirations and negligible opportunities. Qualitative and realist evidence highlighted the importance of context, motivation, future planning and giving young women a central and active role in the development of new interventions.

CONCLUSIONS

Little or no evidence for the effectiveness or cost-effectiveness of any of the interventions to reduce repeat pregnancy in young women was found. Qualitative and realist evidence helped to explain gaps in intervention design that should be addressed. More theory-based, rigorously evaluated programmes need to be developed to reduce unintended repeat pregnancy in young women.

TRIAL REGISTRATION

PROSPERO, CRD42012003168 . Cochrane registration number: i = fertility/0068.

An umbrella review of meta-analyses of interventions to improve maternal outcomes for teen mothers

The purpose of this study was to perform an umbrella review of meta-analyses of intervention studies designed to improve outcomes of pregnant or parenting teenagers. An extensive search retrieved nine reports which provided 21 meta-analyses analyses. Data were extracted by two reviewers. Methodological quality was assessed using the AMSTAR Instrument. Most effect sizes were small but high quality studies showed significant outcomes for reduced low birth weight (RR = 0.60), repeat pregnancies/births (OR = 0.47-0.62), maternal education (OR = 1.21-1.83), and maternal employment (OR = 1.26). Several parenting outcomes (parent-child teaching interaction post-intervention [SMD = -0.91] and at follow-up [SMD = -1.07], and parent-child relationship post-intervention [SMD = -0.71] and at follow-up [SMD = -0.90]) were significant, but sample sizes were very small. Many reports did not include moderator analyses. Behavioral interventions offer limited resources and occur too late to mitigate the educational and social disparities that precede teen pregnancy. Future intervention research and policies that redress the social determinants of early childbearing are recommended.

Motivational Interviewing to Promote Long-Acting Reversible Contraception in Postpartum Teenagers

STUDY OBJECTIVE

To determine if teenage patients receiving prenatal care in an adolescent-focused clinic, emphasizing long-acting reversible contraception (LARC) using motivational interviewing techniques, had higher rates of uptake of postpartum LARC than a control group.

DESIGN AND SETTING

Retrospective cohort study comparing young women who received prenatal care in an adolescent-focused setting with those enrolled in standard prenatal care.

PARTICIPANTS

Adolescents between the ages of 13 and 17 years receiving prenatal care within the Maricopa Integrated Health safety-net system between 2007 and 2014.

INTERVENTIONS

Motivational interviewing within the context of adolescent-focused prenatal care.

MAIN OUTCOME MEASURES

Rates of uptake of LARC within 13 postpartum weeks.

RESULTS

The adjusted rate of LARC for adolescent-focused prenatal care participants by 13 weeks postpartum was 38% (95% confidence interval [CI], 29%-47%) compared with 18% (95% CI, 11%-28%) for standard care participants, with an adjusted odds ratio of LARC use of 2.8 (95% CI, 1.5-5.2). Among patients who received adolescent-focused prenatal care, most (27% vs 12.7%) were using an intrauterine device as opposed to an implantable contraceptive device.

CONCLUSION

Participation in an adolescent-focused antepartum setting using motivational interviewing to emphasize postpartum LARC resulted in nearly 3 times higher rates of uptake compared with standard prenatal care.

Prevalence of rapid repeat pregnancy and associated factors in adolescents in Caruaru, Pernambuco

Abstract Objectives: to determine the prevalence and factors associated with the rapid repeat pregnancy (RRP) in pregnant adolescents. Methods: a cross-sectional study was carried out with pregnant adolescents assisted at the Family Health Strategies in Caruaru-PE from March to August 2013. A questionnaire with sociodemographic, economic, schooling, gynecological, obstetric and contraceptive characteristics was used. The data were analyzed in the Statistical Package for Social Sciences (SPSS), version 20. Binary logistic regression models were used. Results: among the 204 pregnant adolescents interviewed, the data of 26.5% (n = 54) multiparous were analyzed. The occurrence of RRP was 42.6% (n = 23) [95% CI 29.23-56.79]. The variables associated with RRP were non-use of contraceptive methods [OR 7.40 (CI95% 1.56-3.49)] and no previous pregnancy planning [OR 0.19 (95% CI 0.05-0.78)]. Conclusions: the percentage of RRP in adolescents was high. The non-use of contracep-tive methods increased the chances of RRP, while the no previous pregnancy planning decreased the chances of adolescents getting pregnant again without previous program-ming.

Intervention Now to Eliminate Repeat Unintended Pregnancy in Teenagers (INTERUPT): a systematic review of intervention effectiveness and cost-effectiveness, and qualitative and realist synthesis of implementation factors and user engagement

BACKGROUND

The UK has one of the highest rates of teenage pregnancies in Western Europe. One-fifth of these are repeat pregnancies. Unintended conceptions can cause substantial emotional, psychological and educational harm to teenagers, often with enduring implications for life chances. Babies of teenage mothers have increased mortality and are at a significantly increased risk of poverty, educational underachievement and unemployment later in life, with associated costs to society. It is important to identify effective, cost-effective and acceptable interventions.

OBJECTIVES

To identify who is at the greatest risk of repeat unintended pregnancies; which interventions are effective and cost-effective; and what the barriers to and facilitators of the uptake of these interventions are.

DATA SOURCES

We conducted a multistreamed, mixed-methods systematic review informed by service user and provider consultation to examine worldwide peer-reviewed evidence and UK-generated grey literature to find and evaluate interventions to reduce repeat unintended teenage pregnancies. We searched the following electronic databases: MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the Health Technology Assessment Database), EMBASE (Excerpta Medica database), British Nursing Index, Educational Resources Information Center, Sociological Abstracts, Applied Social Sciences Index and Abstracts, BiblioMap (the Evidence for Policy and Practice Information and Co-ordinating Centre register of health promotion and public health research), Social Sciences Citation Index (supported by Web of Knowledge), Research Papers in Economics, EconLit (American Economic Association's electronic bibliography), OpenGrey, Scopus, Scirus, Social Care Online, National Research Register, National Institute for Health Research Clinical Research Network Portfolio and Index to THESES. Searches were conducted in May 2013 and updated in June 2014. In addition, we conducted a systematic search of Google (Google Inc., Mountain View, CA, USA) in January 2014. Database searches were guided by an advisory group of stakeholders.

REVIEW METHODS

To address the topic's complexities, we used a structured, innovative and iterative approach combining methods tailored to each evidence stream. Quantitative data (effectiveness, cost-effectiveness, risk factors and effect modifiers) were synthesised with reference to Cochrane guidelines for evaluating evidence on public health interventions. Qualitative evidence addressing facilitators of and barriers to the uptake of interventions, experience and acceptability of interventions was synthesised thematically. We applied the principles of realist synthesis to uncover theories and mechanisms underpinning interventions (what works, for whom and in what context). Finally, we conducted an overarching narrative of synthesis of evidence and gathered service user feedback.

RESULTS

We identified 8664 documents initially, and 816 in repeat searches. We filtered these to 12 randomised controlled trials (RCTs), four quasi-RCTs, 10 qualitative studies and 53 other quantitative studies published between 1996 and 2012. None of the RCTs was based in the UK. The RCTs evaluated an emergency contraception programme and psychosocial interventions. We found no evidence for effectiveness with regard to condom use, contraceptive use or rates of unprotected sex or use of birth control. Our primary outcome was repeat conception rate: the event rate was 132 of 308 (43%) in the intervention group versus 140 of 289 (48%) for the control goup, with a non-significant risk ratio (RR) of 0.92 [95% confidence interval (CI) 0.78 to 1.08]. Four studies reported subsequent birth rates: 29 of 237 (12%) events for the intervention arm versus 46 out of 224 (21%) for the control arm, with a RR of 0.60 (95% CI 0.39 to 0.93). Many repeat conceptions occurred in the context of poverty, low expectations and aspirations, and negligible opportunities. Service user feedback suggested that there were specific motivations for many repeat conceptions, for example to replace loss or to please a partner. Realist synthesis highlighted that context, motivation, planning for the future and letting young women take control with connectedness and tailoring provide a conceptual framework for future research.

LIMITATIONS

Included studies rarely characterised adolescent pregnancy as intended or unintended, that is interventions to reduce repeat conceptions rarely addressed whether or not pregnancies were intended. Furthermore, interventions were often not clearly defined, had multiple aims and did not indicate which elements were intended to address which aims. Nearly all of the studies were conducted in the USA and focused largely on African American or Hispanic and Latina American populations.

CONCLUSIONS

We found no evidence to indicate that existing interventions to reduce repeat teenage pregnancy were effective; however, subsequent births were reduced by home-based interventions. Qualitative and realist evidence helped to explain gaps in intervention design that should be addressed. More theory-based, rigorously evaluated programmes need to be developed to reduce repeat teenage pregnancy in the UK.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003168. Cochrane registration number: i=fertility/0068.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Effects of Obstetric Complications on Adolescent Postpartum Contraception and Rapid Repeat Pregnancy

STUDY OBJECTIVE

To determine whether complications during pregnancy or at delivery influence postpartum contraception choices and rapid repeat pregnancy rates in adolescent women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This retrospective cohort study included 321 adolescents delivering at UMASS Memorial Healthcare. Complications during pregnancy and delivery along with subsequent contraception use were investigated. Postpartum contraception choice (long-acting reversible contraception [LARC] vs non-LARC) at either delivery, hospitalization discharge, or at postpartum outpatient appointment, and rapid repeat pregnancy rate (pregnancy confirmed within 12 months of index delivery), were analyzed according to pregnancy complications. Comparisons were made with χ² and Fisher exact tests for categorical variables, and with Wilcoxon rank sum test for continuous variables.

RESULTS

Of the study population, 27.7% (n = 89/321) used LARC in the postpartum period. The LARC and non-LARC patient populations differed significantly regarding history of abortion (P = .029), with no differences in obstetric complications between the groups. Of the population, 16.6% (n = 53/320) became pregnant again within 1 year of their index delivery. Those with a rapid repeat pregnancy had significantly increased gravidity (P = .002), parity (P = .003), number of previous spontaneous or therapeutic abortions (P = .026); they were also more like to have nonlive birth as a complication (P = .028), compared with those without repeat pregnancy. No other obstetrical complications were statistically significantly different between the compared groups.

CONCLUSION

Obstetrical complications seem to have little effect on postpartum contraception choice or repeat pregnancy rate with the notable exception of nonlive birth being associated with rapid repeat pregnancy.

The CORALIE study: improving patient education to help new users better understand their oral contraceptive

OBJECTIVES

Combined oral contraceptives (COCs) are the most widely used contraceptive method in Europe. Paradoxically, rates of unintended pregnancy and abortion are still remarkably high. A lack of knowledge about COCs is often reported to lead to poor adherence, suggesting an unmet need for adequate contraceptive counselling. Our objective was to investigate the impact on the knowledge level of users of a structured approach to deliver contraceptive information for a first COC prescription.

METHODS

The Oral Contraception Project to Optimise Patient Information (CORALIE) is a multicentre, prospective, randomised study conducted in France between March 2009 and January 2013. The intervention involved providing either an 'essential information' checklist or unstructured counselling to new COC users. The outcome measure was a questionnaire that assessed whether the information provided to the new user by the gynaecologist had been correctly understood.

RESULTS

One hundred gynaecologists and an expert committee used the Delphi method to develop an 'essential information' checklist, after which 161 gynaecologists were randomised to two groups. Group I (n = 81) used the checklist with 324 new COC users and group II (n = 80) delivered unstructured information to 307 new COC users. The average score for understanding the information delivered during the visit was significantly higher in women in group I than in the women in group II, even after adjustment for age and previous history of pregnancy: 16.48/20 vs 14.27/20 (p < 0.0001).

CONCLUSION

Delivering structured information for a first COC prescription is beneficial for understanding contraception. Our tool could ultimately contribute to increased adherence and should be investigated in a prospective study of long-term outcomes.

Randomized Controlled Trial of Home-Based Hormonal Contraceptive Dispensing for Women At Risk of Unintended Pregnancy

CONTEXT

Women frequently experience barriers to obtaining effective contraceptives from clinic-based providers. Allowing nurses to dispense hormonal methods during home visits may be a way to reduce barriers and improve -effective contraceptive use.

METHODS

Between 2009 and 2013, a sample of 337 low-income, pregnant clients of a nurse home-visit program in Washington State were randomly selected to receive either usual care or enhanced care in which nurses were permitted to provide hormonal contraceptives postpartum. Participants were surveyed at baseline and every three months postpartum for up to two years. Longitudinal Poisson mixed-effects regression analysis was used to examine group differences in gaps in effective contraceptive use, and survival analysis was used to examine time until a subsequent pregnancy.

RESULTS

Compared with usual care participants, enhanced care participants had an average of 9.6 fewer days not covered by effective contraceptive use during the 90 days following a first birth (52.6 vs. 62.2). By six months postpartum, 50% of usual care participants and 39% of enhanced care participants were using a long-acting reversible contraceptive (LARC). In analyses excluding LARC use, enhanced care participants had an average of 14.2 fewer days not covered by effective contraceptive use 0-3 months postpartum (65.0 vs. 79.2) and 15.7 fewer uncovered days 4-6 months postpartum (39.2 vs. 54.9).

CONCLUSION

Home dispensing of hormonal contraceptives may improve women's postpartum contraceptive use and should be explored as an intervention in communities where contraceptives are not easily accessible.

Choice of Postpartum Contraception: Factors Predisposing Pregnant Adolescents to Choose Less Effective Methods Over Long-Acting Reversible Contraception

PURPOSE

The purposes were to determine contraceptive methods pregnant adolescents intend to use postpartum and to understand factors that predispose intention to use less effective birth control than long-acting reversible contraception (LARC).

METHODS

Participants were 247 pregnant minority adolescents in a prenatal program. Intention was assessed by asking "Which of the following methods of preventing pregnancy do you intend to use after you deliver?" Multinomial logistic regression analysis was used to determine factors associated with intent to use nonhormonal (NH) contraception (male/female condoms, abstinence, withdrawal and no method) or short-/medium-acting hormonal (SMH) contraception (birth control pill, patch, vaginal ring, injectable medroxyprogesterone acetate) compared with LARC (implant and intrauterine device) postpartum.

RESULTS

Twenty-three percent intended to use LARC, 53% an SMH method, and 24% an NH method. Participants who intended to use NH or SMH contraceptive methods over LARC were significantly more likely to believe that LARC is not effective at preventing pregnancy, to report that they do not make decisions to help reach their goals and that partners are not important when making contraceptive decisions. Other important factors were having a mother who was aged >19 years at first birth and had not graduated from high school, not having experienced a prior pregnancy or talked with parents about birth control options, and the perception of having limited financial resources.

CONCLUSIONS

Distinct profiles of factors associated with intending to use NH or SMH contraceptive methods over LARC postpartum were identified and may inform future interventions to promote the use of LARC to prevent repeat pregnancy.

Postpartum contraception: a missed opportunity to prevent unintended pregnancy and short inter-pregnancy intervals

BACKGROUND

Women in the postpartum period need effective contraception. Unintended pregnancies soon after childbirth may lead to abortion or short inter-pregnancy intervals associated with adverse outcomes. Using databases for a 6-month period (September 2013-February 2014) we examined the proportion of women attending for abortion in Edinburgh, Scotland who had given birth in the preceding 12 months, and the proportion of women giving birth in this region after an inter-pregnancy interval of 12 months or less. We also surveyed 250 women prior to discharge from the same maternity service about their contraceptive intentions.

RESULTS

Some 75/1175 (6.4%) attending for abortion had given birth within the preceding 12 months and 332/4713 (7.0%) postpartum women gave birth following an inter-pregnancy interval of 12 months or less. When considering parous women, percentages were 13.3% and 13.9%, respectively. The majority (n=237, 96.7%) of postpartum women were not planning another pregnancy within the year but only a minority (n=32, 12.8%) were planning on using long-acting reversible contraception (LARC), namely the implant or intrauterine device. However, 42.8% (n=107) indicated that if the implant or intrauterine contraception could be inserted before they left hospital then they would choose these methods (p<0.0001).

DISCUSSION

Almost one in thirteen women in our population presenting for abortion or giving birth has conceived within 1 year of giving birth. Provision of LARC immediately postpartum appears to be an attractive option to mothers, and could be an important strategy to prevent unintended pregnancy and short inter-pregnancy intervals.

Let's talk about sex (again): advancing the conversation around long-acting reversible contraception for teenagers

Long-acting reversible contraception (LARC) has incredible potential for decreasing teenage pregnancy rates in the USA, but use among adolescents remains low. LARC methods, including intrauterine devices and implants, are recommended as first-line choices for teenagers by multiple medical professional associations. Barriers at the system, provider and patient level persist, but new demonstration projects, in addition to provisions of the Affordable Care Act, show great promise in facilitating LARC use. A renewed national discourse should acknowledge the reality that many US teenagers have sex, that LARC is safe and effective and that LARC offers an opportunity to prevent teenage pregnancy. By encouraging widespread access and use, a large, positive impact across multiple health and economic sectors can be achieved.

The Efficiency of Reproduction Health Education Given to Adolescents during the Postpartum Period

Our research, partly experimental and partly prospective, was conducted for the purpose of evaluating the efficiency of reproductive health education given to adolescents during the postpartum period. The study comprised with 120 adolescents aged 15 to 19 (60 experimental group, 60 control group). Follow-up was conducted every 3 months for a total of 12 months, and the study concluded with 55 individuals from the experimental group and 46 individuals from the control group having participated fully, for the full 12 months. At the end of the research, it was found that the reproductive health knowledge of the experimental (103.10 ± 11.43) and control (99.15 ± 9.53) groups were similar before education. A statistically significant difference was also found between the total points for the scale determining the reproductive health of the experimental and control groups before and after education (P < .001). The socio-demographic variables affecting the total points for the scale determining the reproductive health-protective behavior of women were evaluated by multiple regression analysis; the most effective variables were found to be age and educational status. A statistically significant difference was also found between the total points for the family planning behavior scale of the experimental and control groups before and after education (P < .001). From this, it was understood that reproductive health education given during the postpartum and follow-up periods has a positive effect on adolescents' developing reproductive health behaviors and on creating knowledge and awareness related to family planning behavior. But there needs to be follow-up and supporting specific for adolescents in the current health system.

What do Women Want? Experiences of Low-Income Women with Postpartum Contraception and Contraceptive Counseling

BACKGROUND

Contraceptive counseling can increase postpartum contraception use, yet the optimal method and timing for counseling are unknown. The objective was to investigate preferences of underserved pregnant and postpartum women regarding contraception use and counseling.

METHOD

Surveys regarding contraception experiences and perceptions of contraceptive counseling were conducted with 57 women age 18 and older who were postpartum or antepartum with a previous delivery within 5 years and receiving Medicaid-funded care at an academic medical center. Health literacy was assessed using REALM-7. Responses were analyzed using descriptive statistics.

RESULTS

A majority of women reported unplanned pregnancies (78%). Women using contraception at the time of conception reported "not sure" (30%) and "taken wrong" (30%) as primary reasons for failure. Most subjects had at least a high school level of health literacy (88%), desired to use a postpartum contraceptive method (92%) and had a high self-reported understanding of that method (94%). Most women reported receiving counseling (91%) and stated that the best time for counseling was both before and after childbirth (84%). However, only 60% of subjects intended to use the method they were prescribed at discharge; reasons for changing included side effects (37%), desire for different contraception (23%) and too complicated of a method prescribed (17%).

CONCLUSION

Women perceived the best timing of contraceptive education to be both antepartum and postpartum. Despite a high frequency of prior contraceptive failure, self-reported understanding of the chosen postpartum contraceptive method was high. Contraception counseling should be tailored to a woman's perceived needs, with such education occurring frequently and within the context of her health literacy.

Prenatal contraceptive counseling and method provision after childbirth

Postpartum contraception is undergoing major changes, not only in timing, but also in content. Failure to provide immediate postpartum contraception contributes to the problems of unintended pregnancies and rapid repeat pregnancy because often the highest-risk women do not return for postpartum care. If they do attend that visit, they have often lost the insurance coverage that would enable them to use the most effective forms of birth control. Most of the issues surrounding early initiation of progestin-only methods and breastfeeding have been favorably resolved. In some cases, insurance coverage for delivery has been expanded to cover the costs of providing intrauterine devices and implants before the woman is discharged home. All of these new opportunities shift the burden of counseling about postpartum contraception onto the shoulders of the prenatal care provider. This article provides information about the advantages and disadvantages of providing immediate postpartum contraception with each of the eligible methods so clinicians can provide the needed counseling both during pregnancy and during hospitalization for delivery. It also provides guidance for initiation of bridging contraception, if needed, to initiate a method for a woman later in the postpartum period.

Postpartum contraceptive use in Gondar town, Northwest Ethiopia: a community based cross-sectional study

Background

Addressing family planning in the postpartum period is crucial for better maternal, neonatal and child survival because it enables women to achieve healthy interval between births. The contraceptive behavior of women in the postpartum period is usually different from other times in a woman’s life cycle due to the additional roles and presence of emotional changes. Therefore, this study is conducted with the aim of assessing the contraceptive behavior of women in the postpartum period.

Methods

A community-based cross-sectional study was conducted in August 2013 among women who gave birth one year before the study period in Gondar town, Northwest Ethiopia. Multistage cluster sampling technique was employed to recruit a total of 703 study participants. For data collection, a structured and pretested questionnaire was used. Descriptive statistics were done to characterize the study population using different variables. Bivariate and multiple logistic regression models were fitted. Odds ratios with 95% confidence intervals were computed to identify factors associated with contraceptive use.

Results

Nearly half (48.4%) of the postpartum women were using different types of contraceptives. The most commonly used method was injectable (68.5%). Resumption of mensus [Adjusted Odds Ratio (AOR) = 8.32 95% Confidence Interval (CI): (5.27, 13.14)], age ≤24 years [AOR = 2.36, 95% CI: (1.19, 4.69), duration of 7–9 months after delivery [AOR = 2.26 95% CI: (1.12, 4.54)], and having antenatal care [AOR = 5.76, 95% CI: (2.18, 15.2)] were the factors positively associated with contraceptive use in the extended postpartum period.

Conclusion

Postpartum contraceptive practice was lower as compared to the Ethiopian demographic and health survey 2011 report for urban areas. Strengthening family planning counseling during antenatal care visit and postnatal care would improve contraceptive use in the postpartum period.

Early initiation of postpartum contraception: does it decrease rapid repeat pregnancy in adolescents?

STUDY OBJECTIVE

Rapid repeat adolescent pregnancy is a significant public health concern. An effective and practical means of decreasing unintended second adolescent pregnancies needs to be identified. The objective of this study is to determine if early initiation of contraception, and in particular long acting reversible contraception (LARC), decreases rapid repeat pregnancy among first time adolescent mothers.

DESIGN

Retrospective cohort study.

SETTING

Urban teaching hospital.

PARTICIPANTS

340 first-time adolescent mothers age ≤ 19.

INTERVENTIONS

None, study was retrospective.

MAIN OUTCOME MEASURES

Repeat pregnancy within 2 years.

RESULTS

340 first time adolescent mothers with a documented follow-up time of 2 years had a repeat pregnancy rate of 35%. Average time from delivery to repeat pregnancy was 9.9 ± 6.4 months. Logistic regression analysis comparing adolescents with and without repeat pregnancy revealed that leaving the hospital postpartum without initiating any contraception was associated with significant increase risk of repeat pregnancy (OR = 2.447, 95% CI 1.326-4.515). Follow-up within 8 weeks postpartum was associated with lower chance of repeat pregnancy (OR = 0.322, 95% CI 0.172-0.603). Initiation of a LARC method (either an intrauterine device or etonogestrel subdermal implant) by 8 weeks postpartum was also associated with decreased chance of rapid repeat pregnancy (OR = 0.118, 95% CI 0.035-0.397).

CONCLUSION

Adolescent mothers who initiate a LARC method within 8 weeks of delivery are less likely to have a repeat pregnancy within 2 years than those who choose other methods or no method. First time adolescent mothers should be counseled about this advantage of using LARC.

Contraceptive counseling and postpartum contraceptive use

OBJECTIVE

The objective of the study was to examine the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use.

STUDY DESIGN

The Pregnancy Risk Assessment Monitoring System 2004-2008 data were analyzed from Missouri, New York state, and New York City (n = 9536). We used multivariable logistic regression to assess the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use, defined as any method and more effective methods (sterilization, intrauterine device, or hormonal methods).

RESULTS

The majority of women received prenatal (78%) and postpartum (86%) contraceptive counseling; 72% received both. Compared with those who received no counseling, those counseled during 1 time period (adjusted odds ratio [AOR], 2.10; 95% confidence interval [CI], 1.65-2.67) and both time periods (AOR, 2.33; 95% CI, 1.87-2.89) had significantly increased odds of postpartum use of a more effective contraceptive method (32% vs 49% and 56%, respectively; P for trend < .0001). Results for counseling during both time periods differed by type of health insurance before pregnancy, with greater odds of postpartum use of a more effective method observed for women with no insurance (AOR, 3.51; 95% CI, 2.18-5.66) and Medicaid insurance (AOR, 3.74; 95% CI, 1.98-7.06) than for those with private insurance (AOR, 1.87; 95% CI, 1.44-2.43) before pregnancy. Findings were similar for postpartum use of any contraceptive method, except that no differences by insurance status were detected.

CONCLUSION

The prevalence of postpartum contraceptive use, including the use of more effective methods, was highest when contraceptive counseling was provided during both prenatal and postpartum time periods. Women with Medicaid or no health insurance before pregnancy benefited the most.