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

Abstract

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.

Figure 1

Survey questions used to measure contraceptive preferences. IUD, intrauterine device.

Figure 2

Contraceptive use at various durations postpartum. Percent of women using sterilization, long-acting reversible contraceptives (LARC), hormonal methods, less-effective methods, and no method at baseline, 3 months, and 6 months postpartum among women at all hospitals except Hospital 8 (A) and among women at Hospital 8 (B).

Figure 3

Contraceptive use and method preference at 6 months postpartum. Type of contraceptive method used (A), method preference (B), and elicited method preference (C) at 6 months postpartum. LARC, long-acting reversible contraceptives.

Figure 4

Methods being used at 6 months postpartum among all women who desire a long-acting or permanent method, women who want more children (or are unsure) and desire long-acting reversible contraceptives (LARC), and women who want no more children and desire a long-acting or permanent method.