Low-income women in Texas are not receiving contraception after childbirth, study shows

Low-income women in Texas who have delivered a baby are not getting the contraception they want at their six-week postpartum visit, a new study from the Texas Policy Evaluation Project (TxPEP) shows. Two-thirds of women did not receive the contraception they wanted at their initial postpartum visit, commonly known as the "six-week checkup," leaving them at risk for an unintended pregnancy. While some women (8%) left the visit with a less preferred form of contraception, over half (58%) left with no method at all.

Women who wanted to use an intrauterine device (IUD) or the contraceptive implant, two highly effective methods, faced the greatest difficulty accessing what they wanted with only ten percent of women who wanted them getting them at the first postpartum visit.

By three months postpartum, the women who did not receive the contraception they wanted at the six-week visit were half as likely to be using it as the women who did receive it (41% versus 86%), indicating the crucial importance of the six-week checkup in establishing desired contraceptive use in postpartum women who wish to prevent pregnancy. Women who were not using their desired method were frequently using less-effective methods of contraception, such as condoms, withdrawal, or natural family planning.

"The first postpartum visit, usually scheduled about six weeks after delivery, is extremely important for contraceptive access," said study lead author Kate Coleman-Minahan, co-investigator at TxPEP, nurse practitioner, and assistant professor in the College of Nursing at the University of Colorado. "The time immediately after childbirth can be full of compounding stressors--lack of time, energy, sleep, money, support, or reliable transportation. The six-week checkup is an opportunity for clinicians to provide the support a woman needs to make decisions about if, when, and how to grow her family."

When identifying the difficulties accessing the contraception they wanted, women pointed to clinic- and provider-level barriers. For example, 37% of women were told by physicians to schedule another visit to obtain their desired method. Nearly 1 in 5 women were told they were not eligible for their desired method due to health reasons, but in most cases the advice was not correct: only 28% of these instances were consistent with current evidence-based practice guidelines. Many women reported that providers told them they could not use a method because they were breastfeeding or they had not started menstruating, recommendations that do not align with the Center for Disease Control protocol and put women at risk for pregnancy. Other women reported that their clinics did not stock more expensive contraceptive methods, such as the IUD.

Many women also described complex cost barriers, such as Pregnancy Medicaid insurance expiring after two months, which can place a time crunch on the initial postpartum visit and limit return visits outside of the two-month window. Filling out the clinic paperwork to access income-based discounts in a timely manner also created significant barriers for women.

"The most effective method to prevent pregnancy is the method the woman wants to be using and will continue to use." said Coleman-Minahan. "Expanding Pregnancy Medicaid contraception coverage to at least six months for all women, including immigrants, helping providers provide patient-centered, accurate contraceptive counseling, and supporting clinics in stocking and administering long-acting contraception would go a long way in ensuring women can access the contraception they want, when they want it."

The study results are based on a survey of 685 women administered three months after childbirth at eight hospitals across six Texas cities from 2014-2016. The women either had no insurance or were covered by public insurance, and they did not want to have a baby within the two years following delivery.