Executive Summary
New national data of U.S. reproductive-age women indicates that by three months postpartum, 72% of women were using some type of contraceptive, with only 6% using long-acting reversible contraceptives. In women who chose these methods, just 0.5% of these women became pregnant within 18 months of delivery.
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In comparison, 28% of women relied on hormonal methods and 25% used less effective forms of contraception, data indicate. Study findings indicate that 13-18% of these women became pregnant within 18 months, as did 23% of women using no contraception.
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Insurance-related barriers prevent many women from obtaining long-acting reversible contraception before being discharged from the hospital, researchers note.
Researchers recently looked at national data to investigate women’s patterns of contraceptive use after delivery and the association between method use and risk of pregnancy within 18 months.1 What did they find?
By three months postpartum, 72% of women were using some type of contraceptive; 6% used long-acting reversible contraceptives (LARCs), and 0.5% of these women became pregnant within 18 months of delivery. In comparison, 28% of women relied on hormonal methods, and 25% used less effective forms of contraception. Data indicate 13-18% of these women became pregnant within 18 months, as did 23% of women using no contraception.1
The most troubling statistic? At least 70% of pregnancies among U.S. women in the first year after delivery of a child were unintended. Unintended and closely spaced pregnancies are associated with adverse maternal and child health outcomes, researchers note.1
The research was conducted by the Austin-based Texas Policy Evaluation Project, which includes researchers from The University of Texas at Austin’s Population Research Center, Oakland, CA-based Ibis Reproductive Health, and the University of Alabama – Birmingham. To perform the analysis, the scientists looked at data from the 2006–2010 National Survey of Family Growth (NSFG).
One of the primary reasons researchers decided to use the NSFG for the study was because it allowed them to determine when women initiated contraception postpartum and track the types of methods they used in the months following delivery, notes lead author Kari White, PhD, assistant professor of Health Care Organization and Policy at the University of Alabama at Birmingham.
“This information is not available or is much more limited in other data sources, such as hospital discharge surveys or the Pregnancy Risk Assessment Monitoring System,” White explains. “Another advantage of the NSFG is that it is a nationally representative sample of reproductive aged women in the U.S. and, therefore, can show what is happening at the national level with respect to postpartum contraception.”
Why such low use?
While it is not clear why few postpartum women make use of highly effective methods, chances are it might be due to insurance-related barriers that prevent many women from obtaining long-acting reversible contraception before being discharged from the hospital, researchers note.
In most states, intrauterine devices or the contraceptive implant are not included in the “global” obstetric fee, meaning hospitals will incur a financial loss if a postpartum patient receives a LARC prior to discharge,2 notes Andrew Kaunitz, MD, University of Florida Research Foundation professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine — Jacksonville.
“Some state Medicaid programs have addressed this issue,” says Kaunitz. “If more states follow suit, this would mean more postpartum women in the U.S. will have access to highly effective reversible contraceptives.”
Indeed, more state Medicaid programs are reimbursing for immediate postpartum placement of IUDs and implants, notes Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School of Medicine at the University of California in Los Angeles. California just announced such coverage in its MediCal program, she points out. (To check the progress nationwide, see the American College of Obstetricians and Gynecologists’ LARC web site. It can be accessed at http://bit.ly/1tlMUPw.)
Texas is set to implement separate Medicaid reimbursement for LARC methods immediately following delivery in January 2016. This step is an important one; 74% of unplanned births in the state are publicly funded, according to the Texas Policy Evaluation Project.
White says, “Our team is in the process of following up on our study of unmet demand for postpartum contraception by conducting another prospective study of postpartum women’s contraceptive use in Texas, with a larger sample drawn from six cities in the state. We will be looking at any changes in women’s unmet demand and uptake of immediate postpartum LARC with these data.”
Check your practice
Are you up to date on postpartum LARC use? Clinicians can check out a 2014 webinar on the subject sponsored by the American College of Obstetricians and Gynecologists. Visit the web site at http://bit.ly/1K9R3ui for the webinar.
Looking for information on postpartum insertion of LARC methods? Check out free online training developed by Cardea, a training, organizational development research group with offices in Austin, TX, Oakland, CA, and Seattle for the Olympia-based Washington State Department of Health. Presented by Sarah Prager, MD, MAS, vice chair of the ACOG Committee on Health Care for Underserved Women, the online training offers information and resources on providing intrauterine and subdermal contraception immediately following childbirth. The course addresses indications for immediate postpartum LARC insertion, features videos to demonstrate best practices for postpartum IUD insertion (including how to construct a postpartum uterus model for simulation training), and describes possible complications and appropriate management strategies. It’s designed for healthcare providers, counselors, and administrative staff who work in prenatal care or labor and delivery settings. Visit http://bit.ly/16ZoO2i for more information.
Nelson reminds clinicians that postpartum implants provide at least equivalent pregnancy protection with no worries for consent prior to delivery since they can be placed at any time before the woman is discharged home.
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White K, Teal SB, Potter JE. Contraception after delivery and short interpregnancy intervals among women in the United States. Obstet Gynecol 2015; 125(6):1471-1477.
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Aiken AR, Creinin MD, Kaunitz AM, et al. Global fee prohibits postpartum provision of the most effective reversible contraceptives. Contraception 2014; 90(5):466-467.
