Study finds many low-income women denied contraception at first postpartum visit

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Kate Coleman-Minahan

TxPEP Postpartum Checkup

Only 23% of low-income women in Texas received their desired method of contraception at their first postpartum visit, thus leaving them vulnerable to an unintended pregnancy, according to results of a prospective cohort study.

The survey of 685 women at eight hospitals across six Texas cities, from 2014 to 2016, also concluded that 58% of women left their 6-week checkup with no method of birth control at all. The researchers used open- and closed-ended survey questions to poll the participants and thematic and multivariate logistic regression analyses to examine contraceptive access and barriers, and the method the women used at 3 months postpartum.

“Most prior research focuses on women’s use of contraception postpartum, not whether they can access their desired method of contraception at the first postpartum visit,” said lead author Kate Coleman-Minahan, PhD, FNP-BC, a co-investigator of the Texas Policy Evaluation Project at The University of Texas at Austin, which evaluates the impact of Texas legislation on women’s reproductive health. “This study focuses specifically on whether women are getting the contraception they want at their first postpartum visit and the barriers they face in getting the method they would like to be using.”

The women surveyed either had no insurance or were covered by public insurance. They also did not want to have another baby within 2 years of their current delivery.   

The investigators of the study, which appears in Perspectives on Sexual and Reproductive Health, were surprised that cost was not the only barrier to access to contraception. 

“Even woman with health insurance described a number of clinic-level and provider-level barriers. including having to return for a clinically unnecessary second visit to receive the method and receiving inaccurate contraceptive counseling from providers, such as being told they could not start a method until they’d had a period,” Dr. Coleman-Minahan told Contemporary OB/GYN.

In addition, nearly one in five women were told by their physician that they were not eligible for their desired method of contraception, due to health reasons, when in most cases that advice was incorrect. 

Although less surprising, the study authors found that women who wanted an intrauterine device (IUD) or a contraceptive implant faced the greatest difficulty, with only 10% of them getting IUDs at the first postpartum visit. 

Furthermore, women who did not receive their contraception of choice at their 6-week visit were half as likely to be using it at 3 months postpartum compared to women who did receive what they had requested: 41% versus 86%.

The study also points to other barriers, including the high cost of highly effective methods, difficulty filling out the paperwork needed for income-based discounts, and expiration of insurance like Pregnancy Medicaid.

To improve access to the desired contraceptive method at first postpartum visit in this low-income population, Dr. Coleman-Minahan said Pregnancy Medicaid coverage could be extended to 6 months postpartum, rather than 8 weeks. It also could be expanded to include undocumented women, thus providing them with access to postpartum contraception. Improving financial reimbursement to healthcare facilities that provide IUDs and implants, Dr. Coleman-Minahan said, also would be beneficial.

Clinical recommendations from Dr. Coleman-Minahan include adopting quality care standards that ensure all methods of reversible contraception are stocked and providing same-day access to these methods. Clinicians should also use the Centers for Disease Control and Prevention’s Medical Eligibility Criteria when assessing medical reasons women cannot use certain types of contraception and opportunities for them to obtain training on patient-centered, accurate contraceptive counseling also should be increased.