The Influence of Social Determinants of Health on the Provision of Postpartum Contraceptives in Medicaid

Abstract

Disparities continue to exist in the timely provision of postpartum contraception. This study aimed to identify prevalence and factors associated with postpartum contraception provision among women enrolled in Medicaid. A retrospective cohort study was conducted using the 2014 National Medicaid data, linked to county-level social vulnerability index (SVI) data. Women aged 15–44 with a live birth in 2014 were included. Multivariable logistic regression was used to predict 3-day provision of long-acting reversible contraception (LARC) and 60-day provision of most effective or moderately effective contraceptives (MMEC). Overall, 3-day LARC provision was 0.2% while 60-day MMEC was 36.3%. Significantly lower odds of receiving MMEC was found among women aged 15–20 (adjusted odds ratio[aOR] = 0.87; 95% CI:0.86–0.89) compared to women 20–44 years as well as among Asian women (aOR = 0.69; 95% CI:0.66–0.72) and Hispanic women (aOR = 0.73; 95% CI:0.72–0.75) compared to White women. The provision of postpartum contraception remains low, generally, and needs attention in communities experiencing poor maternal outcomes.

Review of the National Quality Forum's Measure Endorsement Process

“…22 This is particularly applicable in validity testing for performance measures, where patient factors such as disease burden or social determinants of health confound the relationship between measures and health outcomes. [23][24][25] Such confounding is highly likely to lead to ecological fallacy. 19 The existing literature details that failure to account for these known confounders may produce biased evidence for measure validity.…”

Achieving Equity in Postpartum Contraception Access

“…Among Medicaid recipients in Texas, Black patients were more likely and Hispanic patients less likely to receive long-acting reversible contraception (intrauterine device [IUD] or implant) immediately postpartum compared with white patients, and Asian, Hispanic, and "other" race patients were significantly less likely to receive an effective method of contraception in the 60 days postpartum compared with white patients. 16 The United States has a sordid history of eugenics, and racist and coercive public health campaigns incentivizing long-acting and permanent contraception for primarily Black and Hispanic publicly insured people, resulting in contraceptive suspicion. [17][18][19][20] Patients continue to be differentially counseled by race in immediate postpartum long-acting reversible contraception (LARC) contraceptive counseling 19,21,22 and express a preference for early and ongoing counseling from a variety of providers.…”

“…Equity considerations are paramount when considering contraception provisions. Among Medicaid recipients in Texas, Black patients were more likely and Hispanic patients less likely to receive long-acting reversible contraception (intrauterine device [IUD] or implant) immediately postpartum compared with white patients, and Asian, Hispanic, and “other” race patients were significantly less likely to receive an effective method of contraception in the 60 days postpartum compared with white patients 16. The United States has a sordid history of eugenics, and racist and coercive public health campaigns incentivizing long-acting and permanent contraception for primarily Black and Hispanic publicly insured people, resulting in contraceptive suspicion 17–20.…”