Abigail R.A. Aiken

Unmet demand for highly effective postpartum contraception in Texas

OBJECTIVES We aimed to assess womens contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth. METHODS We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18-44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery. RESULTS At 6 months postpartum, 13% of women were using an intrauterine device or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using long-acting reversible contraception (LARC). CONCLUSIONS This study shows a considerable preference for LARC and permanent methods at 6 months postpartum. However, there is a marked discordance between womens method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception. IMPLICATIONS In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at 6 months postpartum. Womens contraceptive needs could be better met by counseling about all methods, by reducing cost barriers and by making LAPM available at more sites.

Requests for Abortion in Latin America Related to Concern about Zika Virus Exposure

With the rapid emergence of Zika virus throughout Latin America and its association with microcephaly, requests for access to abortion medications through online telemedicine have increased in countries where access to safe abortion is not universally available.

Global fee prohibits postpartum provision of the most effective reversible contraceptives.

Early postpartum access to highly effective reversible contraceptives (intrauterine contraceptives (IUCs) and the implant) and sterilization is key to helping women prevent unintended pregnancy.[1] Yet most current hospital reimbursement policies deny postpartum women access to IUCs and implants prior to hospital discharge. For women whose deliveries are covered by private insurance or Medicaid, hospitals receive a global fee based on the diagnosis-related group (DRG) for all delivery-related care. Postpartum sterilization is carved out by insurance companies and Medicaid as a procedure that may be billed separately from the global fee, which in turn means that hospitals are not financially driven to deny such procedures. In contrast, in most states, postpartum IUCs and implants are not carved out for separate reimbursement and the costs of the devices must be deducted from the DRG payment. Since the wholesale acquisition costs for IUCs and implants range from

Rethinking the Pregnancy Planning Paradigm: Unintended Conceptions or Unrepresentative Concepts?

600 to

Are Latina women ambivalent about pregnancies they are trying to prevent? Evidence from the Border Contraceptive Access Study.

775, covering those costs would be fiscally rash. Consequently, most hospitals do not permit postpartum placement of the most effective reversible methods, a policy that not only hinders women’s ability to space their pregnancies but also prohibits an important option for those who have completed childbearing but do not wish to be sterilized. Equally, for women who are covered by Medicaid and desire postpartum sterilization, the twin requirements of a minimum 30-day waiting period after signing the consent form and having that form present in the delivery room still inhibit access.[2] For these women, postpartum placement of IUCs and implants would be a valuable alternative. Although the Affordable Care Act (ACA) may go a long way towards expanding outpatient access to the most effective methods of contraception, it does not specifically facilitate inpatient access to IUC or the implant for new mothers prior to hospital discharge. Placement of IUCs immediately after placental delivery or an implant before hospital discharge is attractive because motivation to use is high, timing is convenient for the woman and provider, and the woman is obviously known not to be pregnant. As Rodriguez and colleagues extensively document in their Commentary in this issue, postpartum placement of these products is also safe for the woman and there are no adverse effects on breastfeeding.[3] (We note, however, that in one study, women in whom the levonorgestrel IUC was placed immediately postpartum were more likely to discontinue breastfeeding than were mothers who delayed placement until 6–8 weeks postpartum.[4]) There is also good evidence of high continuation rates at 6 and 12 months following immediate IUC placement[5,6,7] and of a reduction in the likelihood of repeat pregnancy within 24 months following placement of implants prior to discharge.[8] Perhaps the most compelling reason to provide highly effective reversible contraceptives to new mothers prior to hospital discharge is that women themselves want to use them but often face significant barriers to access. In their article in this issue, Potter and colleagues demonstrated substantial unmet demand for postpartum IUCs and implants. Thirty-four percent of women desired either an IUC or implant (a further 44% desired female or male sterilization), yet only 13% were using IUCs or the implants at 6 months postpartum. Among women who desired an IUC or implant and who wanted more children, 48% ended up using a method as or less effective than condoms at 6 months post-delivery.[9] In addition to improving women’s health, a major advantage of facilitating postpartum placement of IUCs and implants is the potential to save money by preventing unintended births. The reason is that IUCs and implants are the most effective reversible contraceptives; they are in the top-tier effectiveness category [10] because they require no adherence on the part of the woman. Significant cost savings to the Colorado Medicaid program were demonstrated for adolescent mothers receiving postpartum implants:

The Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas

0.78,

Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland

3.54 and

Addressing potential pitfalls of reproductive life planning with patient-centered counseling

6.50 per dollar spent at 12, 24 and 36 months postpartum.[11] Likewise, immediate postpartum placement of IUCs in women covered by Emergency Medicaid (for undocumented immigrants and legal immigrants with less than five years of legal residence) in one Oregon hospital was estimated to save three dollars for every dollar spent.[12] That hospital lost money on women whose obstetrical care was covered by Emergency Medicaid, so in theory it might save money by preventing further such losses. However, in fact it would not save money by using its own funds to cover postpartum IUCs because too few of these women return to it for subsequent obstetrical care. There are of course other obstacles to providing immediate postpartum IUDs and implants to women who are suitable candidates. Catholic hospitals, which provide one-sixth of hospital beds in the United States, do not allow placement of IUCs or implants for contraception. Other difficulties include ensuring an adequate stock of devices, the need for provider training, and the task of coordinating a sufficient volume of skilled providers to be available when required. Yet without the ability for hospitals to bill for postpartum placement separately from the global fee, there is no incentive for these issues to be addressed. Separate billing for postpartum implants and IUCs for women covered by Medicaid is now permitted in ten states (Colorado, Georgia, Iowa, Louisiana, Mississippi, New Mexico, New York, Oklahoma, South Carolina, and Tennessee). No legislative action is needed, just regulatory changes and short-term investments.[3] If this progressive Medicaid policy is adopted in all other states, and should private insurance plans as well as Emergency Medicaid allow separate billing for postpartum IUCs and implants, women and their families will benefit from fewer unintended pregnancies, and health care dollars will be saved.

Factors influencing the likelihood of instrumental delivery success

contraceptives correctly and consistently over time. For women with ambivalent, indifferent or fl uctuating desires, highly effective contraceptives may be unappealing precisely because they negate the possibility of an unplanned (but welcome) conception. Second, planning paradigms may overlook another important facet of women’s pregnancy preferences: emotional orientations. Paradoxically, some women have highly positive emotional responses to the prospect of pregnancy even when they express an immediate, unambivalent desire to avoid conception or a clear intention not to have any more children. Moreover, these emotional responses often provide an indication of the anticipated balance both of immediate consequences of pregnancy (positive and negative) and of future life impacts of childbearing. For example, on the one hand, having a child might be diffi cult economically, and thus delaying or ending childbearing may be viewed as prudent. On the other hand, a child might bring many rewards, including personal fulfi llment, feelings of closeness to a partner, or a sense of progress or purpose in life. If the positives outweigh the negatives, or if economic or other circumstances seem unlikely to improve over time anyway, women might have favorable emotional orientations toward pregnancy and childbearing despite expressing intentions or desires to delay or avoid conception. For these women, standard timing-based defi nitions of unintended pregnancy fail to capture the trade-offs of a possible pregnancy, which, in turn, may not be well represented by the language of planning. Third, conventional planning paradigms are imbued with the normative belief that unintended pregnancies are uniformly negative events that necessarily result in adverse consequences. Yet the complexity of women’s prospective pregnancy desires and emotional orientations toward pregnancy demonstrates clearly that while some unintended pregnancies would indeed be undesired, others would be welcome. Still others would not be entirely unanticipated, and these may also be viewed positively. Emotional orientations toward pregnancy seem to offer an indication of the psychosocial stress that would likely arise should a pregnancy occur, and some studies have suggested that such orientations may be more important than timingbased intentions in predicting negative outcomes. Moreover, other studies have shown that women’s preconception desires and emotional orientations toward pregnancy may evolve after conception has occurred. Thus, a pregnancy that was not explicitly desired or whose Approximately half of pregnancies occurring each year in the United States are unintended: They either occurred too soon or were not intended at any time. This commonly cited statistic is testament to the dominance of unintended pregnancy as a public health benchmark for measuring and improving women’s reproductive health. In addition to its use as a public health metric, this timing-based defi nition of unintended pregnancy is refl ected in pregnancy planning paradigms in clinical practice. According to these paradigms, women are expected to map out their intentions regarding whether and when to conceive, and to formulate specifi c plans to follow through on their intentions.

Happiness about unintended pregnancy and its relationship to contraceptive desires among a predominantly Latina cohort.

CONTEXT Womens retrospective reports of their feelings about a pregnancy and of its intendedness are often inconsistent, particularly among Latinas. Interpretation of this incongruence as ambivalence overlooks the possibility that happiness about the prospect of pregnancy and desire to prevent pregnancy need not be mutually exclusive. METHODS Data from the 2006-2008 Border Contraceptive Access Study--a prospective study of 956 Latina oral contraceptive users aged 18-44 in El Paso, Texas--were used to compare womens planned pill use and childbearing intentions with their feelings about a possible pregnancy. Associations between womens feelings and their perceptions of their partners feelings were examined using logistic regression. Prospective and retrospective intentions and feelings were compared among women who became pregnant during the study. RESULTS Forty-one percent of women who planned to use the pill for at least another year and 34% of those who wanted no more children said they would feel very or somewhat happy about becoming pregnant in the next three months. Perceiving that a male partner would feel very upset about a pregnancy was negatively associated with happiness about the pregnancy among both women who planned to continue pill use and those who wanted no more children (coefficients, -4.4 and -3.9, respectively). Of the 36 women who became pregnant during the study, 24 reported feeling very happy about the pregnancy in retrospect, while only 14 had prospectively reported feeling happy about a possible pregnancy. CONCLUSION Intentions and happiness appear to be distinct concepts for this sample of Latina women.