To investigate women's patterns of contraceptive use after delivery and the association between method use and risk of pregnancy within 18 months.
We used the 2006-2010 National Survey of Family ...Growth to examine women's contraceptive use after delivery and at 3, 6, 12, and 18 months after giving birth. The sample included 3,005 births that occurred within 3 years of the survey date and for which information on contraceptive use was available. We estimated multivariable-adjusted Cox regression models to assess the association between women's method use and risk of pregnancy within 18 months after delivery. We also examined the percentage of pregnancies occurring 18 months or less after the index birth that were unintended.
Between delivery and 3 months postpartum, contraceptive use increased from 21% to 72%. At 3 months, 13% of women used permanent contraception, 6% used long-acting reversible contraceptives, 28% used other hormonal methods, and 25% relied on less-effective methods; the distribution of method use was similar in subsequent months. Among women using hormonal methods, 12.6% became pregnant within 18 months of delivery or less compared with 0.5% using permanent and long-acting contraception (adjusted hazard ratio HR 21.2, 95% confidence interval CI 6.17-72.8). Additionally, 17.8% of women using less-effective methods (HR 34.8, 95% CI 9.26-131) and 23% using no method (HR 43.2, 95% CI 12.3-152) became pregnant 18 months or less. At least 70% of pregnancies within 1 year after delivery were unintended.
Few women use long-acting reversible contraceptives after delivery, and those using less-effective methods have an increased risk of unintended pregnancy.
II.
We examined the association between quality of postpartum contraceptive counseling and changes in contraceptive method preference between delivery and 3-months postpartum.
We used data from 1167 ...postpartum women delivering at eight hospitals in Texas who did not initiate contraception in the hospital. We conducted baseline and 3-month follow-up interviews to ask women about the method they would prefer to use at 6-months postpartum, postpartum contraceptive counseling, reproductive history, and demographic characteristics. We measured quality of postpartum contraceptive counseling with seven items related to satisfaction and information received. High-quality counseling was defined as meeting all seven criteria. We used logistic regression to predict the primary outcome of changes in preferred method by contraceptive counseling and described contraceptive counseling and changes in preferred method by demographic characteristics.
Receipt of high-quality postpartum contraceptive counseling was reported by 26%. At 3-months postpartum 70% of participants reported the same contraceptive preferences by category of effectiveness that they expressed at the time of delivery. Spanish-speaking, Hispanic foreign-born, and lower socioeconomic status women were less likely to receive high-quality counseling than their counterparts. High-quality counseling was associated with lower odds of preferring a less effective method (OR: 0.31, 95% CI: 0.18–0.52) and changing preference from an IUD or implant (OR: 0.34, 95% CI: 0.17–0.68).
High-quality postpartum contraceptive counseling is relatively rare and occurs less often among low SES and immigrant women. High-quality counseling appears to reinforce preferences for effective contraception.
Training healthcare providers to provide high-quality contraceptive counseling to all postpartum women may reduce contraceptive disparities related to race/ethnicity and social class.
To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the ...introduction of House Bill 2 in 2013.
In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood-affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open.
For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than $100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05).
Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.
To assess whether indicators of limited access to services explained changes in rates of second-trimester abortion after implementation of a restrictive abortion law in Texas.
We used cross-sectional ...vital statistics data on abortions performed in Texas before (November 1, 2011-October 31, 2012) and after (November 1, 2013-October 31, 2014) implementation of Texas' abortion law. We conducted monthly mystery client calls for information about abortion facility closures and appointment wait times to calculate distance from women's county of residence to the nearest open Texas facility, the number of open abortion facilities in women's region of residence (facility network size), and days until the next consultation visit. We estimated mixed-effects logistic regression models to assess the association between obtaining abortion care after the law's implementation and having a second-trimester abortion (12 weeks of gestation or more), after adjustment for distance, network size, and wait times.
Overall, 64,902 Texas-resident abortions occurred in the period before the law was introduced and 53,174 occurred after its implementation. After implementation, 14.5% of abortions were performed at 12 weeks of gestation or more, compared with 10.5% before the law (P<.001; unadjusted odds ratio OR 1.45; 95% CI 1.40-1.50). Adjusting for distance to the nearest facility and facility network size reduced the odds of having a second-trimester abortion after implementation (OR 1.17; 95% CI 1.10-1.25). Women living 50-99 miles from the nearest facility (vs less than 10 miles) had higher odds of second-trimester abortion (OR 1.24; 95% CI 1.11-1.39), as did women in regions with less than one facility per 250,000 reproductive-aged women compared with women in areas that had 1.5 or more facilities (OR 1.57; 95% CI 1.41-1.75). After implementation, women waited 1 to 14 days for a consultation visit; longer waits were associated with higher odds of second-trimester abortion.
Increases in second-trimester abortion after the law's implementation were due to women having more limited access to abortion services.
Abstract Objective In 2013, Texas passed legislation restricting abortion services. Almost half of the state's clinics had closed by April 2014, and there was a 13% decline in abortions in the 6 ...months after the first portions of the law went into effect, compared to the same period 1 year prior. We aimed to describe women's experiences seeking abortion care shortly after clinics closed and document pregnancy outcomes of women affected by these closures. Study design Between November 2013 and November 2014, we recruited women who sought abortion care at Texas clinics that were no longer providing services. Some participants had appointments scheduled at clinics that stopped offering care when the law went into effect; others called seeking care at clinics that had closed. Texas resident women seeking abortion in Albuquerque, New Mexico, were also recruited. Results We conducted 23 in-depth interviews and performed a thematic analysis. As a result of clinic closures, women experienced confusion about where to go for abortion services, and most reported increased cost and travel time to obtain care. Having to travel farther for care also compromised their privacy. Eight women were delayed more than 1 week, two did not receive care until they were more than 12 weeks pregnant and two did not obtain their desired abortion at all. Five women considered self-inducing the abortion, but none attempted this. Conclusions The clinic closures resulted in multiple barriers to care, leading to delayed abortion care for some and preventing others from having the abortion they wanted. Implications The restrictions on abortion facilities that resulted in the closure of clinics in Texas created significant burdens on women that prevented them from having desired abortions. These laws may also adversely affect public health by moving women who would have had abortions in the first trimester to having second-trimester procedures.
Abstract Objectives In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians ...to have hospital-admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect. Study design We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (< 12 weeks vs. ≥ 12 weeks). Results In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012–April 2013 to November 2013–April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15–44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the state's six ASCs. Conclusions The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions. Implications Supply-side restrictions on abortion — especially restrictions on medical abortion — can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.
Fertility surveys have rarely asked people who are using contraception about the contraceptive method they would like to be using, implicitly assuming that those who are contracepting are using the ...method they want. In this commentary, we review evidence from a small but growing body of work that oftentimes indicates this assumption is untrue. Discordant contraceptive preferences and use are relatively common, and unsatisfied preferences are associated with higher rates of method discontinuation and subsequent pregnancy. We argue that there is opportunity to center autonomy and illuminate the need for and quality of services by building on this research and investing in the development of survey items that assess which method people would like to use, as well as their reasons for nonpreferred use. The widespread adoption of questions regarding method preferences could bring indicators of reproductive health services into closer alignment with the needs of the people they serve.
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