Medicaid claims data among a North Carolina cohort show that women were less likely to fill a contraceptive claim within 90 days after preterm birth.1

“We linked data from a pregnancy medical home program, where women with Medicaid in North Carolina are eligible for that program,” says Christine Tucker, PhD, MPH, assistant professor in the department of maternal and child health at Gillings School of Global Public Health, University of North Carolina at Chapel Hill. “We found that less than half the women in our sample had a contraceptive claim within 90 days of delivery. It was lower for women with a preterm birth — and especially for women who had a preterm birth and more than two children.”

Researchers collected data on contraception billed by Medicaid. They could not determine whether people used condoms or other barrier methods. Researchers studied health parity, including whether women had more than two children and a preterm birth. When comparing women by demographics, researchers found that women who were older, married, and college graduates had a lower prevalence of contraceptive use, Tucker says.

“They were all lower-income,” she adds. “If they were married, they were less likely than unmarried women to obtain contraception.”

One theory for this difference is that women in those groups might desire a pregnancy sooner than younger women. “Those are just questions — not the main point of our study,” Tucker says.

Researchers were interested in learning more about women who had a preterm birth. “Literature out there suggests that women who have a previous preterm birth are at higher risk for another preterm birth or a poorer birth outcome,” Tucker says. “Longer pregnancy intervals and avoiding unintended pregnancy can help prevent preterm birth.”

Investigators theorized it would be harder for women to access contraception after a preterm birth because they would be caring for a medically fragile infant, she adds.

“If your baby is in the NICU [neonatal intensive care unit], and you’re there all the time, it may be harder for you to get an appointment for yourself to get contraception,” Tucker explains. “There’s qualitative data that women are so focused on medical complications and caring for their child that their needs go on the back burner.”

Also, women who have a preterm birth have shorter pregnancies, which means there is less time for a conversation with their healthcare providers about contraception.

“I think our postpartum care models need to be more flexible and more patient-centered,” Tucker says. “In this case, the women who qualified for Medicaid needed to get a message about contraception within 90 days, and that might not have been when they were ready for it,” Tucker says. “Their reproductive life plan might not have been on their mind when they had a young infant.”

This means healthcare providers need to be more flexible and find creative ways to serve the mother and infant, she adds. For example, some pediatricians conduct postpartum depression and anxiety screening of new mothers during well-child visits.

“I’m not sure how widespread this is, but I think there’s a lot of movement around the fourth trimester,” Tucker says. “We spend all this time with women when they’re pregnant, and they have extensive prenatal care appointments, but the fourth trimester is when women are so vulnerable. Depression and anxiety are high.”

Postpartum women experience bleeding, night sweats, lack of sleep, challenges with breastfeeding, and other issues. They only have one doctor’s visit at six weeks, Tucker explains.

“There’s a movement to think about the fourth trimester as a continuum, so the mother and baby are together at that time, and let’s treat and serve them together,” she adds.

The study found an association between preterm birth and less use of highly effective contraception. Women were much less likely to submit a claim for an intrauterine device after a preterm birth, Tucker says. Solutions include expanding Medicaid. Some women have Medicaid during their pregnancy, but do not have access to health insurance coverage after their pregnancy, Tucker says.

Another solution is the national Alliance for Innovation on Maternal Health (AIM) patient safety bundle related to postpartum care basics for maternal safety. (Find more information at: https://safehealthcareforeverywoman.org/patient-safety-bundles/postpartum-care-basics-1/.)

“Nationally, there is a lot of funding around maternal mortality and severe maternal morbidity. New safety bundles were implemented with small, evidence-based interventions,” Tucker says. Two postpartum bundles help providers give a warm handoff from the maternity care provider to the primary care provider.

Another best practice is for obstetricians/gynecologists to start a conversation about contraception prenatally. “Those conversations should be patient-centered,” Tucker says. “It might not be the most important thing to the woman to prevent another preterm birth.”

For instance, the woman might want another baby soon after giving birth. Conversations must take into account her needs and view the woman as the expert in her own needs, Tucker explains.

“The clinician can explain how she might be at higher risk of a second preterm birth if she just had one, and the clinician can explain the evidence on birth spacing,” she adds. “But, ultimately, this needs to be a shared decision-making process. If we just say, ‘Don’t get pregnant in the next 18 months,’ it doesn’t open the door for the woman to have an open conversation with her provider.”

REFERENCE

  1. Tucker C, Berrien K, Menard MK, et al. Preterm birth and receipt of postpartum contraception among women with Medicaid in North Carolina. Matern Child Health J 2020;24:640-650.