Abortion patients' decision making about where to obtain out-of-state care following Texas' 2021 abortion ban

OBJECTIVE

To assess pregnant Texans' decisions about where to obtain out-of-state abortion care following the September 2021 implementation of Senate Bill 8 (SB8), which prohibited abortions after detectable embryonic cardiac activity.

DATA SOURCE

In-depth telephone interviews with Texas residents ≥15 years of age who obtained out-of-state abortion care after SB8's implementation.

STUDY DESIGN

This qualitative study explored participants' experiences identifying and contacting abortion facilities and their concerns and considerations about traveling out of state. We used inductive and deductive codes in our thematic analysis describing people's decisions about where to obtain care and how they evaluated available options.

DATA COLLECTION

Texas residents self-referred to the study from flyers we provided to abortion facilities in Arkansas, Colorado, Kansas, Louisiana, Mississippi, New Mexico, and Oklahoma. We also enrolled participants from a concurrent online survey of Texans seeking abortion care.

PRINCIPAL FINDINGS

Participants (n = 65) frequently obtained referral lists for out-of-state locations from health-care providers, and a few received referrals to specific facilities; however, referrals rarely included the information people needed to decide where to obtain care. More than half of the participants prioritized getting the soonest appointment and often contacted multiple locations and traveled further to do so; others who could not travel further typically waited longer for an appointment. Although the participants rarely cited state abortion restrictions or cost of care as their main reason for choosing a location, they often made sacrifices to lessen the logistical and economic hardships that state restrictions and out-of-state travel costs created. Informative abortion facility websites and compassionate scheduling staff solidified some participants' facility choice.

CONCLUSIONS

Pregnant Texans made difficult trade-offs and experienced travel-related burdens to obtain out-of-state abortion care. As abortion bans prohibit more people from obtaining in-state care, efforts to strengthen patient navigation are needed to reduce care-seeking burdens as this will support people's reproductive autonomy.

Comparing preference for and use of medication abortion in Texas after policy changes in 2014 and 2018

OBJECTIVES

Assess preferences for and use of medication abortion in Texas after implementation of two policy changes: a 2013 state law restricting medication abortion and the FDA label change for mifepristone in 2016 nullifying some of this restriction.

STUDY DESIGN

We analyzed surveys conducted in 2014 and 2018 with abortion patients at 10 Texas abortion facilities. We calculated the percentage of all respondents with an initial preference for medication abortion by survey year, and the type of abortion obtained or planned to obtain among those who were at <10 weeks of gestation. We used multivariable-adjusted mixed-effects Poisson regression models to assess factors associated with medication abortion preference and actual/planned use.

RESULTS

Overall, 156 (41%) of 376 respondents in 2014 and 247 (55%) of 448 respondents in 2018 reported initial preference for medication abortion (Prevalence ratio [PR]: 1.28; 95% CI 1.03-1.59). Among those who were <10 weeks of gestation and initially preferred medication abortion, 39 of 124 (31%) obtained or were planning to obtain the method in 2014, compared with 188 of 223 (84%) in 2018 (PR: 2.65; 95% CI: 1.69-4.15). After multivariable adjustment, respondents who initially preferred medication abortion and were 7 to 9 weeks of gestation at the time of their ultrasonography (vs <7 weeks) were less likely to obtain or plan to obtain the method (PR: 0.69; 95% CI: 0.57-0.84).

CONCLUSIONS

Abortion patients were more likely to prefer and obtain or plan to obtain their preferred medication abortion after legal restrictions in Texas were nullified.

IMPLICATIONS

State policies can affect people's ability to obtain their preferred abortion method. Efforts to provide both abortion options whenever possible, and inform people where each can be obtained, remains an important component of person-centered care despite increasing state abortion restrictions and bans following the reversal of Roe v Wade.

Meeting Preferences for Specific Contraceptive Methods: An Overdue Indicator

Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.

Evidence-based family planning services among publicly funded providers in Texas

BACKGROUND

Healthy Texas Women (HTW) is a fee-for-service family planning program that excludes affiliates of abortion providers. The HTW network includes providers who participate in Title X or the state Family Planning Program (FPP) and primary care providers without additional family planning funding (HTW-only). The objective of this study is to compare client volume and use of evidence-based practices among HTW providers.

METHODS

Client volume was determined from administrative data on unduplicated HTW clients served in fiscal year (FY) 2017. A sample of 114 HTW providers, stratified by region, completed a 2018 survey about contraceptive methods offered, adherence to evidence-based contraceptive provision, barriers to offering IUDs and implants, and counseling/referrals for pregnant patients. Differences by funding source were assessed using t-tests and chi-square tests.

RESULTS

Although HTW-only providers served 58% of HTW clients, most (72%) saw < 50 clients in FY2017. Only 5% of HTW providers received Title X or FPP funding, but 46% served ≥ 500 HTW clients. HTW-only providers were less likely than Title X providers to offer hormonal IUDs (70% vs. 92%) and implants (66% vs 96%); offer same-day placement of IUDs (21% vs 79%) and implants (21% vs 83%); and allow patients to delay cervical cancer screening when initiating contraception (58% vs 83%; all p < 0.05). There were few provider-level differences in counseling/referrals for unplanned pregnancy (p > 0.05).

CONCLUSIONS

HTW-only providers served fewer clients and were less likely to follow evidence-based practices. Program modifications that strengthen the provider network and quality of care are needed to support family planning services for low-income Texans.

Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States

IMPORTANCE

Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade.

OBJECTIVE

To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022.

EXPOSURES

Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8.

MAIN OUTCOMES AND MEASURES

Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation.

RESULTS

Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend).

CONCLUSIONS AND RELEVANCE

Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception

OBJECTIVE

To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program.

STUDY DESIGN

In this prospective study conducted between October 2014 and March 2016, we evaluated participants' desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type.

RESULTS

Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use).

CONCLUSIONS

In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods.

IMPLICATIONS

State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients' ability to obtain their preferred method.

Improving assessment of demand for postpartum tubal ligation among publicly insured women in Texas

OBJECTIVE

To assess an alternative method for estimating demand for postpartum tubal ligation and evaluate reproductive trajectories of low-income women who did not obtain a desired procedure.

STUDY DESIGN

In a 2-year cohort study of 1700 publicly insured women who delivered at 8 hospitals in Texas, we identified those who had an unmet demand for tubal ligation prior to discharge from the hospital. We classified unmet demand as explicit or prompted based on survey questions that included a prompt regarding whether the respondent would like to have had a tubal ligation at the time of delivery. We assessed persistence of demand for permanent contraception, contraceptive use, and repeat pregnancies among all study participants who wanted but did not get a postpartum procedure.

RESULTS

Some 426 women desired a postpartum tubal ligation; 219 (51%) obtained one prior to discharge. Among the 207 participants with unmet demand, 62 (30%) expressed an explicit preference for the procedure, while 145 (70%) were identified from the prompt. Most with unmet demand still wanted permanent contraception 3 months after delivery (156/184), but only 23 had obtained interval procedures. By 18 months, the probability of a woman with unmet demand conceiving a pregnancy that she would likely carry to term was 12.5% (95% CI: 8.3%-18.5%).

CONCLUSIONS

The majority of unmet demand for postpartum tubal ligation among publicly insured women in Texas was uncovered via a prompt and would not have been evident in clinical records or from consent forms. Women unable to obtain a desired procedure had a substantial chance of pregnancy within 18 months after delivery.

IMPLICATIONS

Estimates of unmet demand for postpartum tubal ligation based on clinical records and consent forms likely underestimate desire for permanent contraception. Among low-income women in Texas, those with unmet demand for postpartum tubal ligation require improved access to effective contraception.

Border-state abortions increased for Texas residents after House Bill 2

OBJECTIVES

To assess changes in Texas-resident border-state abortions, medication abortions, and abortions ≥22 weeks from last menstrual period (LMP) before and after implementation of House Bill 2 (HB2) in November 2013 and before and after the US Supreme Court's decision regarding HB2 in June 2016.

STUDY DESIGN

We conducted an interrupted time series analysis using 2012-2017 data on Texas-resident abortions in Arkansas, Louisiana, Oklahoma, and New Mexico. Data on procedure type and gestational age were available only for abortions in New Mexico.

RESULTS

Border states reported 762 Texas-resident abortions in 2012, 1,673 in 2014, and 1,475 in 2017. Texas-resident abortions in all border states nearly doubled following HB2's implementation (incidence rate ratio [IRR]=1.92, 95% CI: 1.67-2.20). Border-state abortions then decreased by 19% after the 2016 US Supreme Court decision, compared to the period prior to the decision and after HB2's implementation (IRR=0.81, 95% CI: 0.73-0.91). From 2012 to 2014, the proportion of Texas-resident abortions in New Mexico that were medication abortion increased from 5% to 20% (p < 0.001) and the proportion that were ≥22 weeks from LMP decreased from 40% to 23% (p < p<0.001). Texas vital statistics undercounted annual out-of-state abortions, reporting only 13%-73% of abortions reported by border-state clinics during the study period.

CONCLUSIONS

HB2 was associated with increases in border-state abortions for Texas residents, including in the number of those ≥22 weeks from LMP. Border-state abortions declined after the Supreme Court ruled HB2 unconstitutional yet remained higher than pre-HB2 levels.

IMPLICATIONS STATEMENT

Abortion restrictions that severely curtail access may result in increases in travel out of state for care. Documenting out-of-state abortions is important for evaluating broader policy impacts and to prepare for future service disruptions. Texas residents may have more limited options for care if border states enact restrictive abortion laws.

Short-acting hormonal contraceptive continuation among low-income postpartum women in Texas

OBJECTIVE

The objective was to assess continuation of the pill, patch, ring or injectable (i.e., short-acting hormonal contraception); characteristics associated with discontinuation; and subsequent method use among low-income postpartum women in Texas.

STUDY DESIGN

Using a 24-month cohort study of 1700 women who delivered in eight Texas hospitals and were uninsured or publicly insured at the time of delivery, we focused on 456 women who used short-acting hormonal contraception within 6 months after delivery. We classified this sample according to characteristics and method preference, and estimated rates of discontinuation and associated predictors using life tables and Cox models. We assessed reasons for discontinuation and subsequent contraceptive use among those who discontinued.

RESULTS

Roughly half used the pill and half used the injectable. One hundred seventy-eight (39%) expressed a baseline preference for the method they used, 162 (36%) preferred a long-acting reversible contraception method, and 41 (9%) preferred sterilization. After 1 year, 72% had discontinued [95% confidence interval (CI) 67.1-75.7]. Foreign-born Hispanic women were less likely to discontinue than U.S.-born Hispanics [adjusted hazard ratio (aHR), 0.65; 95% CI 0.50-0.84]. Those who wanted a more effective method (aHR, 1.44; 95% CI 1.12-1.85) and those who lost insurance coverage (aHR, 1.47; 95% CI 1.12-1.92) were more likely to discontinue. The most common reasons for discontinuation were side effects and access/cost. Of those who discontinued, 243 (68%) switched to a less effective or no method. Only 47 (13%) switched to their preferred method.

CONCLUSIONS

Short-acting hormonal contraceptive discontinuation is high in this population. Many switch to less effective methods after discontinuation despite preferring methods at least as effective as the pill, patch, ring or injectable.

IMPLICATIONS

Expanding contraceptive coverage in the 2 years after delivery should be a state and federal policy priority. In clinics, providers should discuss contraceptive preferences throughout pregnancy and the interpregnancy interval.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Breastfeeding Initiation, Duration, and Supplementation Among Mexican-Origin Women in Texas

BACKGROUND

Mexican-origin women breastfeed at similar rates as white women in the United States, yet they usually breastfeed for less time. In our study, we seek to identify differences in Mexican-origin women's breastfeeding intentions, initiation, continuation, and supplementation across nativity and country-of-education groups.

METHODS

The data are from a prospective cohort study of postpartum women ages 18 to 44 recruited from 8 Texas hospitals. We included 1235 Mexican-origin women who were born and educated in either Texas or Mexico. Women were interviewed at delivery and at 3, 6, 12, 18, and 24 months post partum. Breastfeeding intentions and initiation were reported at baseline, continuation was collected at each interview, and weeks until supplementation was assessed for both solids and formula. Women were classified into 3 categories: born and educated in Mexico, born and educated in the United States, and born in Mexico and educated in the United States.

RESULTS

Breastfeeding initiation and continuation varied by nativity and country of birth, although all women reported similar breastfeeding intentions. Women born and educated in Mexico initiated and continued breastfeeding in higher proportions than women born and educated in the United States. Mexican-born and US-educated women formed an intermediate group. Early supplementation with formula and solid foods was similar across groups, and early supplementation with formula negatively impacted duration across all groups.

CONCLUSIONS

Nativity and country of education are important predictors of breastfeeding and should be assessed in pediatric and postpartum settings to tailor breastfeeding support. Support is especially warranted among US-born women, and additional educational interventions should be developed to forestall early supplementation with formula across all acculturation groups.

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.

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

CONTEXT

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

METHODS

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

RESULTS

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

CONCLUSION

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

Providing Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence

OBJECTIVE

To explore organizations' experiences providing family planning during the first year of an expanded primary care program in Texas.

DATA SOURCES

Between November 2014 and February 2015, in-depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors.

STUDY DESIGN

Interviews addressed organizational capacities to expand family planning and integrate services with primary care.

DATA EXTRACTION

Interview transcripts were analyzed using a theme-based approach. Themes were compared across the three types of organizations.

PRINCIPAL FINDINGS

Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients' other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence-based.

CONCLUSIONS

Many primary care organizations in Texas initially lacked the capacity to provide evidence-based family planning services that women's health organizations already provided.

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

OBJECTIVE

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

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Does information about abortion safety affect Texas voters' opinions about restrictive laws? A randomized study

OBJECTIVE

The objective was to assess whether information about abortion safety and awareness of abortion laws affect voters' opinions about medically unnecessary abortion regulations.

STUDY DESIGN

Between May and June 2016, we randomized 1200 Texas voters to receive or not receive information describing the safety of office-based abortion care during an online survey about abortion laws using simple random assignment. We compared the association between receiving safety information and awareness of recent restrictions and beliefs that ambulatory surgical center (ASC) requirements for abortion facilities and hospital admitting privileges requirements for physicians would make abortion safer. We used Poisson regression, adjusting for political affiliation and views on abortion.

RESULTS

Of 1200 surveyed participants, 1183 had complete data for analysis: 612 in the information group and 571 in the comparison group. Overall, 259 (46%) in the information group and 298 (56%) in the comparison group believed that the ASC requirement would improve abortion safety (p=.008); 230 (41%) in the information group and 285 (54%) in the comparison group believed that admitting privileges would make abortion safer (p<.001). After multivariable adjustment, the information group was less likely to report that the ASC [prevalence ratio (PR): 0.82; 95% confidence interval (CI): 0.72-0.94] and admitting privileges requirements (PR: 0.76; 95% CI: 0.65-0.88) would improve safety. Participants who identified as conservative Republicans were more likely to report that the ASC (82%) and admitting privileges requirements (83%) would make abortion safer if they had heard of the provisions than if they were unaware of them (ASC: 52%; admitting privileges: 47%; all p<.001).

CONCLUSIONS

Informational statements reduced perceptions that restrictive laws make abortion safer. Voters' prior awareness of the requirements also was associated with their beliefs.

IMPLICATIONS

Informational messages can shift scientifically unfounded views about abortion safety and could reduce support for restrictive laws. Because prior awareness of abortion laws does not ensure accurate knowledge about their effects on safety, it is important to reach a broad audience through early dissemination of information about new regulations.

Barriers to Offering Vasectomy at Publicly Funded Family Planning Organizations in Texas

Few publicly funded family planning clinics in the United States offer vasectomy, but little is known about the reasons this method is not more widely available at these sources of care. Between February 2012 and February 2015, three waves of in-depth interviews were conducted with program administrators at 54 family planning organizations in Texas. Participants described their organization’s vasectomy service model and factors that influenced how frequently vasectomy was provided. Interview transcripts were coded and analyzed using a theme-based approach. Service models and barriers to providing vasectomy were compared by organization type (e.g., women’s health center, public health clinic) and receipt of Title X funding. Two thirds of organizations did not offer vasectomy on-site or pay for referrals with family planning funding; nine organizations frequently provided vasectomy. Organizations did not widely offer vasectomy because they could not find providers that would accept the low reimbursement for the procedure or because they lacked funding for men’s reproductive health care. Respondents often did not perceive men’s reproductive health care as a service priority and commented that men, especially Latinos, had limited interest in vasectomy. Although organizations of all types reported barriers, women’s health centers and Title X-funded organizations more frequently offered vasectomy by conducting tailored outreach to men and vasectomy providers. A combination of factors operating at the health systems and provider level influence the availability of vasectomy at publicly funded family planning organizations in Texas. Multilevel approaches that address key barriers to vasectomy provision would help organizations offer comprehensive contraceptive services.

Nativity, Country of Education, and Mexican-Origin Women's Breastfeeding Behaviors in the First 10 Months Postpartum

BACKGROUND

Breastfeeding is associated with numerous health benefits for the infant and mother. Latina women in the United States have historically had high overall rates of initiation and duration of breastfeeding. However, these rates vary by nativity and time lived in the United States. Exclusive breastfeeding patterns among Latina women are unclear. In this study, we investigate the current and exclusive breastfeeding patterns of Mexican-origin women at four time points from delivery to 10 months postpartum to determine the combined association of nativity and country of education with breastfeeding duration and supplementation.

METHODS

Data are from the Postpartum Contraception Study, a prospective cohort study of postpartum women ages 18-44 recruited from three hospitals in Austin and El Paso, Texas. We included Mexican-origin women who were born in either the United States or Mexico in the analytic sample (n = 593).

RESULTS

Women completing schooling in Mexico had higher rates of overall breastfeeding throughout the study period than women educated in the United States, regardless of country of birth. This trend held in multivariate models while diminishing over time. Women born in Mexico who completed their schooling in the United States were least likely to exclusively breastfeed.

DISCUSSION

Country of education should also be considered when assessing Latina women's risk for breastfeeding discontinuation. Efforts should be made to identify the barriers and facilitators to breastfeeding among US-educated Mexican-origin women to enhance existing breastfeeding promotion efforts in the United States.

Barriers to Offering Vasectomy at Publicly Funded Family Planning Organizations in Texas

Few publicly funded family planning clinics in the United States offer vasectomy, but little is known about the reasons this method is not more widely available at these sources of care. Between February 2012 and February 2015, three waves of in-depth interviews were conducted with program administrators at 54 family planning organizations in Texas. Participants described their organization’s vasectomy service model and factors that influenced how frequently vasectomy was provided. Interview transcripts were coded and analyzed using a theme-based approach. Service models and barriers to providing vasectomy were compared by organization type (e.g., women’s health center, public health clinic) and receipt of Title X funding. Two thirds of organizations did not offer vasectomy on-site or pay for referrals with family planning funding; nine organizations frequently provided vasectomy. Organizations did not widely offer vasectomy because they could not find providers that would accept the low reimbursement for the procedure or because they lacked funding for men’s reproductive health care. Respondents often did not perceive men’s reproductive health care as a service priority and commented that men, especially Latinos, had limited interest in vasectomy. Although organizations of all types reported barriers, women’s health centers and Title X-funded organizations more frequently offered vasectomy by conducting tailored outreach to men and vasectomy providers. A combination of factors operating at the health systems and provider level influence the availability of vasectomy at publicly funded family planning organizations in Texas. Multilevel approaches that address key barriers to vasectomy provision would help organizations offer comprehensive contraceptive services.

Women's Knowledge of and Support for Abortion Restrictions in Texas: Findings from a Statewide Representative Survey

CONTEXT

States have passed numerous laws restricting abortion, and Texas passed some of the most restrictive legislation between 2011 and 2013. Information about women's awareness of and support for the laws' provisions could inform future debates regarding abortion legislation.

METHODS

Between December 2014 and January 2015, some 779 women aged 18-49 participated in an online, statewide representative survey about recent abortion laws in Texas. Poisson regression analysis was used to assess correlates of support for a law that would make obtaining an abortion more difficult. Women's knowledge of specific abortion restrictions in Texas and reasons for supporting these laws were also assessed.

RESULTS

Overall, 31% of respondents would support a law making it more difficult to obtain an abortion. Foreign-born Latinas were more likely than whites to support such a law (prevalence ratio, 1.5), and conservative Republicans were more likely than moderates and Independents to do so (2.3). Thirty-six percent of respondents were not very aware of recent Texas laws, and 19% had never heard of them. Among women with any awareness of the laws, 19% supported the requirements; 42% of these individuals said this was because such laws would make abortion safer.

CONCLUSIONS

Many Texas women of reproductive age are unaware of statewide abortion restrictions, and some support these requirements because of misperceptions about the safety of abortion. Advocates and policymakers should address these knowledge gaps in efforts to protect access to legal abortion.

Impact of Clinic Closures on Women Obtaining Abortion Services After Implementation of a Restrictive Law in Texas

OBJECTIVES

To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013.

METHODS

In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood-affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open.

RESULTS

For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than $100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05).

CONCLUSIONS

Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.

Effect of Removal of Planned Parenthood from the Texas Women's Health Program

BACKGROUND

Texas is one of several states that have barred Planned Parenthood affiliates from providing health care services with the use of public funds. After the federal government refused to allow (and courts blocked) the exclusion of Planned Parenthood affiliates from the Texas Medicaid fee-for-service family-planning program, Texas excluded them from a state-funded replacement program, effective January 1, 2013. We assessed rates of contraceptive-method provision, method continuation through the program, and childbirth covered by Medicaid before and after the Planned Parenthood exclusion.

METHODS

We used all program claims from 2011 through 2014 to examine changes in the number of claims for contraceptives according to method for 2 years before and 2 years after the exclusion. Among women using injectable contraceptives at baseline, we observed rates of contraceptive continuation through the program and of childbirth covered by Medicaid. We used the difference-in-differences method to compare outcomes in counties with Planned Parenthood affiliates with outcomes in those without such affiliates.

RESULTS

After the Planned Parenthood exclusion, there were estimated reductions in the number of claims from 1042 to 672 (relative reduction, 35.5%) for long-acting, reversible contraceptives and from 6832 to 4708 (relative reduction, 31.1%) for injectable contraceptives (P<0.001 for both comparisons). There was no significant change in the number of claims for short-acting hormonal contraceptive methods during this period. Among women using injectable contraceptives, the percentage of women who returned for a subsequent on-time contraceptive injection decreased from 56.9% among those whose subsequent injections were due before the exclusion to 37.7% among those whose subsequent injections were due after the exclusion in the counties with Planned Parenthood affiliates but increased from 54.9% to 58.5% in the counties without such affiliates (estimated difference in differences in counties with affiliates as compared with those without affiliates, -22.9 percentage points; P<0.001). During this period in counties with Planned Parenthood affiliates, the rate of childbirth covered by Medicaid increased by 1.9 percentage points (a relative increase of 27.1% from baseline) within 18 months after the claim (P=0.01).

CONCLUSIONS

The exclusion of Planned Parenthood affiliates from a state-funded replacement for a Medicaid fee-for-service program in Texas was associated with adverse changes in the provision of contraception. For women using injectable contraceptives, there was a reduction in the rate of contraceptive continuation and an increase in the rate of childbirth covered by Medicaid. (Funded by the Susan T. Buffett Foundation.).

Women's experiences seeking abortion care shortly after the closure of clinics due to a restrictive law in Texas

OBJECTIVE

In 2013, Texas passed legislation restricting abortion services. Almost half of the state's clinics had closed by April 2014, and there was a 13% decline in abortions in the 6 months after the first portions of the law went into effect, compared to the same period 1 year prior. We aimed to describe women's experiences seeking abortion care shortly after clinics closed and document pregnancy outcomes of women affected by these closures.

STUDY DESIGN

Between November 2013 and November 2014, we recruited women who sought abortion care at Texas clinics that were no longer providing services. Some participants had appointments scheduled at clinics that stopped offering care when the law went into effect; others called seeking care at clinics that had closed. Texas resident women seeking abortion in Albuquerque, New Mexico, were also recruited.

RESULTS

We conducted 23 in-depth interviews and performed a thematic analysis. As a result of clinic closures, women experienced confusion about where to go for abortion services, and most reported increased cost and travel time to obtain care. Having to travel farther for care also compromised their privacy. Eight women were delayed more than 1 week, two did not receive care until they were more than 12 weeks pregnant and two did not obtain their desired abortion at all. Five women considered self-inducing the abortion, but none attempted this.

CONCLUSIONS

The clinic closures resulted in multiple barriers to care, leading to delayed abortion care for some and preventing others from having the abortion they wanted.

IMPLICATIONS

The restrictions on abortion facilities that resulted in the closure of clinics in Texas created significant burdens on women that prevented them from having desired abortions. These laws may also adversely affect public health by moving women who would have had abortions in the first trimester to having second-trimester procedures.

Perceived Interest in Vasectomy among Latina Women and their Partners in a Community with Limited Access to Female Sterilization

The low prevalence of vasectomy among Latino men in the United States is often attributed to cultural characteristics despite limited evidence supporting this hypothesis. We assessed male partners' perceived willingness to undergo vasectomy through surveys with 470 Mexican-origin women who did not want more children in El Paso, Texas. Overall, 32% of women reported that their partner would be interested in getting a vasectomy. In multivariable analysis, completing high school (OR=2.03 [1.05, 3.95]), having some college education (OR=2.97 [1.36, 6.48]) or receiving US government assistance (OR=1.95 [1.1, 3.45]) was associated with partners' perceived interest. Additionally, we conducted two focus groups on men's knowledge and attitudes about vasectomy with partners of a subsample of these women. Despite some misperceptions, male partners were willing to get a vasectomy, but were concerned about cost and taking time off work to recover. Health education and affordable vasectomy services could increase vasectomy use among Mexican-origin men.

Geographic Variation in Characteristics of Postpartum Women Using Female Sterilization

BACKGROUND

Southern states have higher rates of female sterilization compared with other areas of the United States, and the reasons for this are not well understood. We examined whether low-income and racial/ethnic minority women, who were previous targets of coercive practices, disproportionately report using sterilization in the South.

METHODS

We used data from 12 states participating in the Pregnancy Risk Assessment Monitoring System that collected information on women's contraceptive method use between 2006 and 2009. We categorized states according to geographic region: South, Midwest/West, and Northeast. Within each region, we computed the percentage of women using sterilization according to their demographic and obstetric characteristics and estimated multivariable-adjusted prevalence ratios to evaluate whether the same characteristics were associated with sterilization use.

FINDINGS

The percentage of postpartum women using sterilization ranged from 5.0% to 9.9% in the Northeast, 8.9% to 10.6% in the Midwest/West, and 11.6% to 22.4% in the South. Women in nearly all subgroups in Southern states were more likely to use sterilization than women in the Northeast. After multivariable adjustment, there were no differences in the prevalence of sterilization for Blacks compared with Whites in the Northeast (0.76; 95% CI, 0.55-1.06), Midwest/West (0.91; 95% CI, 0.80-1.04), and South (0.96; 95% CI, 0.85-1.07). Women with Medicaid-paid deliveries (vs. private insurance) had a higher prevalence of sterilization in all regions (p < .05).

CONCLUSIONS

These findings do not indicate that low-income and racial/ethnic minority women in the South use sterilization at disproportionately higher rates compared with other regions, and suggest that other differences, such as social norms and family planning policies, may contribute to this geographic variation.

Women's experiences seeking publicly funded family planning services in Texas

CONTEXT

Little is known about low-income women's and teenagers' experiences accessing publicly funded family planning services, particularly after policy changes are made that affect the cost of and access to such services.

METHODS

Eleven focus groups were conducted with 92 adult women and 15 teenagers in nine Texas metropolitan areas in July-October 2012, a year after legislation that reduced access to subsidized family planning was enacted. Participants were recruited through organizations that serve low-income populations. At least two researchers independently coded the transcripts of the discussions and identified main themes.

RESULTS

Although most women were not aware of the legislative changes, they reported that in the past year, they had had to pay more for previously free or low-cost services, use less effective contraceptive methods or forgo care. They also indicated that accessing affordable family planning services had long been difficult, that applying and qualifying for programs was a challenge and that obtaining family planning care was harder than obtaining pregnancy-related care. As a result of an inadequate reproductive health safety net, women experienced unplanned pregnancies and were unable to access screening services and follow-up care. Teenagers experienced an additional barrier, the need to obtain parental consent. Some women preferred to receive family planning services from specialized providers, while others preferred more comprehensive care.

CONCLUSION

Women in Texas have long faced challenges in obtaining subsidized family planning services. Legislation that reduced access to family planning services for low-income women and teenagers appears to have added to those challenges.

Abortion access and state variation in observed unintended pregnancy

OBJECTIVE

The state-level proportion of pregnancies that are unintended is an important social and public health indicator, and comparisons between states inform policy discussions. Unintended pregnancy is measured as a composite of abortions and unintended births, each of which is measured with error. We investigate whether between-state differences in abortion access and demand may bias comparisons between states' unintended pregnancy proportions when pregnancy intentions are misreported.

STUDY DESIGN

We algebraically specify the model currently used to estimate unintended pregnancy, extend it to include underreporting, and simulate the impact of underreporting on observed unintended pregnancy. Comparing the impact of underreporting across states, we identify levels of underreporting at which between-state comparisons are compromised.

RESULTS

We find that underreporting of unintended pregnancies could bias between-state comparisons when reporting of unintended pregnancies is less than 90-95%.

CONCLUSION

Current methods for estimating state-level unintended pregnancy proportions may underestimate unintended pregnancy to a greater degree in places with less abortion, and between-state comparisons may be biased. Estimates of state-level unintended pregnancy proportions would be more comparable if adjustment for completeness of retrospective underreporting were included in the estimation process.

IMPLICATIONS

Estimates of unintended pregnancy should be adjusted for nonsampling error and include variances based on sampling and nonsampling error in order to permit robust comparisons between states, between populations, and across time. More research on the fidelity of retrospective reporting of pregnancy intention would facilitate this endeavor.

The impact of reproductive health legislation on family planning clinic services in Texas

We examined the impact of legislation in Texas that dramatically cut and restricted participation in the state's family planning program in 2011 using surveys and interviews with leaders at organizations that received family planning funding. Overall, 25% of family planning clinics in Texas closed. In 2011, 71% of organizations widely offered long-acting reversible contraception; in 2012-2013, only 46% did so. Organizations served 54% fewer clients than they had in the previous period. Specialized family planning providers, which were the targets of the legislation, experienced the largest reductions in services, but other agencies were also adversely affected. The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women's access to family planning services.

Change in abortion services after implementation of a restrictive law in Texas

OBJECTIVES

In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians to have hospital-admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect.

STUDY DESIGN

We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (< 12 weeks vs. ≥ 12 weeks).

RESULTS

In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012-April 2013 to November 2013-April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15-44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the state's six ASCs.

CONCLUSIONS

The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions.

IMPLICATIONS

Supply-side restrictions on abortion - especially restrictions on medical abortion - can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.

Unmet demand for highly effective postpartum contraception in Texas

OBJECTIVES

We aimed to assess women's contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth.

METHODS

We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18-44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery.

RESULTS

At 6 months postpartum, 13% of women were using an intrauterine device or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using long-acting reversible contraception (LARC).

CONCLUSIONS

This study shows a considerable preference for LARC and permanent methods at 6 months postpartum. However, there is a marked discordance between women's method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception.

IMPLICATIONS

In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at 6 months postpartum. Women's contraceptive needs could be better met by counseling about all methods, by reducing cost barriers and by making LAPM available at more sites.

Hypertension among oral contraceptive users in El Paso, Texas

On the U.S.-Mexico border, residents frequently cross into Mexico to obtain medications or medical care. We previously reported relatively high prevalence of hypertension among Latina oral contraceptive users in El Paso, particularly those obtaining pills over the counter (OTC) in Mexico. Here, we examine factors associated with having hypertension among 411 OTC users and 399 clinic users. We also assess hypertension awareness and interest in using blood pressure kiosks. Women age 35 to 44 and who had BMI ≥ 30 kg/m2 had higher odds of having hypertension. 59% of hypertensive women had unrecognized hypertension, and 77% of all participants would use a blood pressure kiosk; there were no significant differences between clinic and OTC users. Alternative approaches to increase access to health screenings are needed in this setting, where OTC pill use among women with unrecognized hypertension confers unique health risks.

Reconsidering racial/ethnic differences in sterilization in the United States

OBJECTIVE

Cross-sectional studies have found that low-income and racial/ethnic minority women are more likely to use female sterilization and less likely to rely on a partner's vasectomy than women with higher incomes and whites. However, studies of pregnant and postpartum women report that racial/ethnic minorities, particularly low-income minority women, face greater barriers in obtaining a sterilization than do whites and those with higher incomes. In this paper, we address this apparent contradiction by examining the likelihood a woman gets a sterilization following each delivery, which removes from the comparison any difference in the number of births she has experienced.

STUDY DESIGN

Using the 2006-2010 National Survey of Family Growth, we fit multivariable-adjusted logistic and Cox regression models to estimate odds ratios and hazard ratios for getting a postpartum or interval sterilization, respectively, according to race/ethnicity and insurance status.

RESULTS

Women's chances of obtaining a sterilization varied by both race/ethnicity and insurance. Among women with Medicaid, whites were more likely to use female sterilization than African Americans and Latinas. Privately insured whites were more likely to rely on vasectomy than African Americans and Latinas, but among women with Medicaid-paid deliveries reliance on vasectomy was low for all racial/ethnic groups.

CONCLUSIONS

Low-income racial/ethnic minority women are less likely to undergo sterilization following delivery compared to low-income whites and privately insured women of similar parities. This could result from unique barriers to obtaining permanent contraception and could expose women to the risk of future unintended pregnancies.

IMPLICATIONS

Low-income minorities are less likely to undergo sterilization than low-income whites and privately insured minorities, which may result from barriers to obtaining permanent contraception, and exposes women to unintended pregnancies.

Variation in postpartum contraceptive method use: results from the Pregnancy Risk Assessment Monitoring System (PRAMS)

OBJECTIVE

The National Survey of Family Growth has been a primary data source for trends in US women's contraceptive use. However, national-level data may mask differences in contraceptive practice resulting from variation in local policies and norms.

STUDY DESIGN

We used the Pregnancy Risk Assessment Monitoring System, a survey of women who are 2-4 months postpartum. Information on women's current method was available for 18 reporting areas from 2000 to 2009. Using the two most recent years of data, we computed the weighted proportion of women using specific contraceptive methods according to payment for delivery (Medicaid or private insurance) and examined differences across states. We used log binomial regression to assess trends in method use in 8 areas with consecutive years of data.

RESULTS

Across states, there was a wide range of use of female sterilization (7.0-22.6%) and long-acting reversible contraception (LARC; 1.9-25.5%). Other methods, like vasectomy and the patch/ring, had a narrower range of use. Women with Medicaid-paid deliveries were more likely to report female sterilization, LARC and injectables as their method compared to women with private insurance. LARC use increased ≥18% per year, while use of injectables and oral contraceptives declined by 2.5-10.6% annually.

CONCLUSIONS

The correlation in method-specific prevalence within states suggests shared social and medical norms, while the larger variation across states may reflect both differences in norms and access to contraception for low-income women. Surveys of postpartum women, who are beginning a new segment of contraceptive use, may better capture emerging trends in US contraceptive method mix.

IMPLICATIONS

There is considerable variation in contraceptive method use across states, which may result from differences in state policies and funding for family planning services, local medical norms surrounding contraceptive practice, and women's and couples' demand or preference for different methods.

The Growth of Protestantism in Brazil and Its Impact on Male Earnings, 1970-2000

Protestantism has expanded rapidly in Brazil in recent decades. The question we tackle in this paper is whether Protestantism has had a positive influence on male earnings in this setting, either through its influence on health and productivity, by way of social networks or employer favor and reduced discrimination, or through other mechanisms. We tackle the problem of the selectivity of religious conversion and affiliation using microdata from the Brazilian censuses of 1970, 1980, 1991, and 2000, and analyzing the association between Protestantism and earnings at the group rather than the individual level. Our results show a strong association between the proportion of Protestants in a region, and the earnings of men in one educational group: those with less than five years of education. Upon introducing race into our models, we found that the association between religion and the earnings of less educated men is concentrated in regions in which there is a substantial non-white population. The relationships we have uncovered contribute to the literature on racial inequality and discrimination in Brazil, which to date has given little space to the role of religion in moderating the pernicious effect of race on economic outcomes in Brazil. The substantial association we found between religion and earnings contrasts with much of the research that has been carried out on the influence of religion on earnings in the United States.

Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy

OBJECTIVE

Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers.

STUDY DESIGN

We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively.

RESULTS

With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved.

CONCLUSION

A revised Medicaid sterilization policy could potentially honor women's reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds.

IMPLICATION

Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year.

Are Latina women ambivalent about pregnancies they are trying to prevent? Evidence from the Border Contraceptive Access Study

CONTEXT

Women's retrospective reports of their feelings about a pregnancy and of its intendedness are often inconsistent, particularly among Latinas. Interpretation of this incongruence as ambivalence overlooks the possibility that happiness about the prospect of pregnancy and desire to prevent pregnancy need not be mutually exclusive.

METHODS

Data from the 2006-2008 Border Contraceptive Access Study--a prospective study of 956 Latina oral contraceptive users aged 18-44 in El Paso, Texas--were used to compare women's planned pill use and childbearing intentions with their feelings about a possible pregnancy. Associations between women's feelings and their perceptions of their partner's feelings were examined using logistic regression. Prospective and retrospective intentions and feelings were compared among women who became pregnant during the study.

RESULTS

Forty-one percent of women who planned to use the pill for at least another year and 34% of those who wanted no more children said they would feel very or somewhat happy about becoming pregnant in the next three months. Perceiving that a male partner would feel very upset about a pregnancy was negatively associated with happiness about the pregnancy among both women who planned to continue pill use and those who wanted no more children (coefficients, -4.4 and -3.9, respectively). Of the 36 women who became pregnant during the study, 24 reported feeling very happy about the pregnancy in retrospect, while only 14 had prospectively reported feeling happy about a possible pregnancy.

CONCLUSION

Intentions and happiness appear to be distinct concepts for this sample of Latina women.

Effects of the Age-Education Structure of Female Workers on Male Earnings in Brazil

The main concern of this study is the impact that an increase in female participation within the labor force has on the earnings of males in Brazil. Previous research considered these transitions for male workers, but did not include female workers when estimating various effects on earnings. The 1970, 1980, 1991, and 2000 Brazilian Demographic Censuses were used for this analysis. Results suggest a significant negative impact on male earnings in 1970 as a result of the share of female workers. This effect has been decreasing over time, as the coefficients from more recent years are positive. Changes in age and educational composition make a substantial difference on the estimation of male earnings in Brazil. The method developed in this study is not infallible, but it improves previous estimates by including the relationship among compositional changes, female labor force participation, and earnings, thus going beyond the direct impact of age and education.