Barriers to postpartum contraception in Texas and pregnancy within 2 years of delivery

The postpartum period has long been recognized as a critical time for women to initiate contraception; their motivation to avoid pregnancy is high and they have access to health care at delivery and often in the initial months postpartum. Although most public and private insurance policies now cover contraception, specific obstacles to immediate postpartum access to highly effective methods remain.These barriers include insurance rules that prohibit inclusion of the fee for an intrauterine device (IUD) or implant placed immediately after delivery in the global delivery reimbursement, the 30-day waiting period between consent and procedure for Medicaid sterilization, and limited or no postpartum contraceptive coverage for women whose prenatal care or deliveries are paid by some forms of Medicaid. Given the risks associated with rapid repeat pregnancies, many have called for the removal of these barriers.

However, the argument for removing barriers and increasing access would be strengthened if more was known about the demand for long-acting reversible contraception (LARC) and female and male sterilization at the time of delivery and afterward. Although information about actual use of sterilization and LARC after delivery is available, little is known about women’s preferences for highly effective methods and when they would like to access them. Additionally, retrospective information from national and state-level data sets can be used to measure the incidence of unintended pregnancies in the 2 years after delivery, but it is hard to know how many of these pregnancies might have been postponed or averted had the demand for highly effective contraception been met.

In this study of postpartum women’s contraceptive preferences and use in the postpartum period in Texas, we addressed these questions by collecting information on the contraceptive methods that women wanted to be using, the level of demand for long-acting or permanent methods, and the barriers women encountered in accessing their preferred method. These data enable us to estimate the proportion of pregnancies occurring within 2 years of delivery that could have been averted through improved access to highly effective contraception in this setting.