Postpartum weight loss in overweight and obese women using the etonogestrel subdermal implant: a pilot study

ObjectiveTo compare weight loss during the first 6 months postpartum in overweight and obese women using the etonogestrel implant, placed in the immediate postpartum period, with that of controls using nonhormonal contraception, utilizing a pilot design.Study designPilot, prospective cohort study. Analysis groups were divided by body mass index (overweight: 25–29.9 kg/m²; Class I Obesity: 30–34.5 kg/m²; Class II Obesity: 35–39.9 kg/m²) and grouped by use of etonogestrel implant or nonhormonal contraception for all outcomes. Primary outcome was the proportion of women in each group returning to pregravid weight by 6 months postpartum. Secondary outcomes included waist circumference, motivation to lose weight, eating habits, physical activity, feasibility of study procedures and assessment of recruitment potential in the first 6 months postpartum.ResultsA total of 127 women enrolled between June 2014 and August 2015. Fifty-seven chose the etonogestrel implant for immediate postpartum contraception while 70 chose nonhormonal contraceptives. Six months after delivery, about half of women in each group returned to within 1.5 kg of pregravid weight (42% etonogestrel [ENG]-implant vs. 67% nonhormonal methods, p=.19). Retention rates were high with over 75% of total study population providing study data at 6 months. Two nonhormonal contraceptive users conceived in the first 4 months postpartum.ConclusionNo statistical difference in percentage return to pregravid weight was detected between groups, but data suggest that a somewhat lower proportion of implant users lost weight at 6 months. Rapid recruitment, high retention and marked acceptance of immediate ENG implant use demonstrate feasibility for a larger, adequately powered trial.ImplicationsImmediate postpartum insertion of the ENG implant is safe and effective. Study findings suggest modest interference in overweight and obese women's ability to lose gestational weight. If future research demonstrates no statistical difference, increased uptake in immediate implant use should occur in most women, including those who are overweight or obese.     

Contraceptive implants and lactation

The safety and efficacy of four contraceptive implants, plant, Implanon, Nestorone and Elcometrine, have been evaluated during use in the postpartum period by lactating women. These implants provide highly effective contraceptive protection with no negative effect on breastfeeding or infant growth and development. Breastfeeding women initiating Norplant use in the second postpartum month experience significantly longer periods of amenorrhea than do untreated women or intrauterine device users. After weaning, the bleeding pattern is similar to that observed in non-nursing women. Norplant use does not affect bone turnover and density during lactation. Norplant and Implanon release orally active progestins while Nestorone and Elcometrine implants release an orally inactive progestin, which represents an advantage since the infant should be free of steroidal effects. The infant's daily intake of steroids (estimated from concentrations in maternal milk during the first month of use) range from 90 to 100 ng of levonorgestrel (Norplant), 75-120 ng of etonogestrel (Implanon), and 50 ng and 110 ng of Nestorone (Nestorone and Elcometrine implants, respectively). Nursing women needing contraception may use progestin-only implants when nonhormonal methods are not available or acceptable. Implants that deliver orally active steroids should only be used after 6 weeks postpartum to avoid transferring of steroids to the newborn.     

Premature introduction of progestin-only contraceptive methods during lactation

Experts on contraceptive technology concur that progestin-only methods can be used safely during lactation. However, very few studies exist of the effects on lactation of the introduction of progestin-only methods prior to the sixth postpartum week. Since progesterone withdrawal is the likely stimulus that initiates lactogenesis, it appears necessary for natural progesterone levels to decline to baseline before a progestin-only contraceptive is initiated. There-fore, the use of such contraceptive methods should be delayed for at least 3 days after the birth. Non-hormonal methods remain the first choice category of contraceptive methods for breastfeeding women, since there is no possibility that they will interfere with lactation. Progestin-only methods comprise a viable and often desirable next choice category, although the timing of their commencement must be determined with care in order to support lactation.     

Effects of breastfeeding on postpartum weight loss among U.S. women

ObjectiveThe aim of this study is to evaluate the effects of breastfeeding on maternal weight loss in the 12 months postpartum among U.S. women.MethodsUsing data from a national cohort of U.S. women conducted in 2005–2007 (N = 2102), we employed propensity scores to match women who breastfed exclusively and non-exclusive for at least three months to comparison women who had not breastfed or breastfed for less than three months. Outcomes included postpartum weight loss at 3, 6, 9, and 12 months postpartum; and the probability of returning to pre-pregnancy body mass index (BMI) category and the probability of returning to pre-pregnancy weight.ResultsCompared to women who did not breastfeed or breastfed non-exclusively, exclusive breastfeeding for at least 3 months resulted in 3.2 pound (95% CI: 1.4,4.7) greater weight loss at 12 months postpartum, a 6.0-percentage-point increase (95% CI: 2.3,9.7) in the probability of returning to the same or lower BMI category postpartum; and a 6.1-percentage-point increase (95% CI: 1.0,11.3) in the probability of returning to pre-pregnancy weight or lower postpartum. Non-exclusive breastfeeding did not significantly affect any outcomes.ConclusionOur study provides evidence that exclusive breastfeeding for at least three months has a small effect on postpartum weight loss among U.S. women.     

Conformity with current guidelines on oral contraceptive prescribing for breastfeeding women: a New Mexico survey

BACKGROUND: National and international contraceptive guidelines reflect expert opinion that recommends against the use of estrogen-containing hormonal contraception in the early postpartum period. This study was undertaken to estimate providers' practices in prescribing hormonal contraception to breastfeeding women. METHODS: A 19-item survey was mailed to 397 obstetrician gynecologists, midwives and family physicians in the state of New Mexico. The survey included items covering attitudes about the impact of hormonal contraception on breastfeeding and prescribing practices. One hundred ninety-nine (50%) providers completed the survey. RESULTS: The majority (70%) of providers prescribe progestin-only contraceptive methods to breastfeeding women within the first 6 weeks. Despite these recommendations, a sizable minority of providers prescribe combined pills in the early postpartum period: 27% of providers have prescribed combined pills and 13% of providers, mostly those in a university setting, routinely recommend them within the first 6 weeks postpartum. CONCLUSION: Most providers follow expert recommendations regarding the initiation of hormonal contraception for breastfeeding women.     

The effect of immediate postpartum levonorgestrel contraceptive implant use on breastfeeding and infant growth: a randomized controlled trial

Objective

This study assessed whether immediate postpartum insertion of levonorgestrel contraceptive implants is associated with a difference in infant growth from birth to 6 months, onset of lactogenesis, or breastfeeding continuation at 3 and 6 months postpartum compared to delayed insertion at 6 to 8 weeks postpartum.

Effect of two kinds of different combined oral contraceptives use on bone mineral density in adolescent women

BackgroundSteroid hormonal contraceptives are highly effective and widely used. Most studies have shown a negative effect of combined oral contraceptives (COCs) on the bone mineral density (BMD) of adolescents. The study was conducted to compare BMD among users of ethinylestradiol/desogestrel, users of ethinylestradiol/cyproterone acetate and nonhormonal control subjects in women aged 16–18 years.Study DesignThe study included 450 women 16–18 years of age. One hundred fifty women were using ethinylestradiol/desogestrel, 150 women were using ethinylestradiol/cyproterone acetate, and 150 women were using nonhormonal contraception as control subjects. BMD ofthe lumbar spine and femoral neck was obtained using dual-energy X-ray absorptiometry, and mean BMD changes in COCs users and nonusers were compared.ResultsAt 24 months of treatment, lumbar spine and femoral neck mean BMD values in women (n=127) who used ethinylestradiol/desogestrel were slightly lower compared with baseline, but these effects did not reach statistical significance (p=.837 and p=.630, respectively). The mean lumbar spine and femoral neck BMD values in women (n=134) who used ethinylestradiol/cyproterone acetate were slightly higher compared with baseline, but there was no statistical significance (p=.789 and p=.756, respectively). The increases in mean percent change in lumbar spine and femoral neck BMD in the ethinylestradiol/cyproterone acetate group were less than those in the control group (1.88% vs. 0.30% and 0.98% vs. 0.49%, respectively). There were no significant differences in mean BMD of the lumbar spine and femoral neck between the users of ethinylestradiol/desogestrel or ethinylestradiol/cyproterone acetate and nonusers (p>.05).ConclusionOur study indicates that 2 years of COCs therapy had no significant effect on bone density in adolescents, but it remains unknown whether therapy longer than 2 years has a significant adverse effect on the attainment of peak bone mass.     

Uso de la anticoncepción con solo gestágenos en atención primaria: estudio GESTAGAP

AimTo estimate the prevalence of use of progestin-only contraceptive among women who request reversible contraception in Primary Care (PC).DesignMulticentre cross-sectional study.SettingPrimary Care Health Care Centres (Madrid).ParticipantsWomen aged 16-50 years old, users of reversible contraception, who speak Spanish, and had attended the Primary Care Centre in the last year.Main measurementsPrimary outcome: contraceptive method used: Contraception with progestins-only (yes/no). Age, parity, country of origin, type of contraceptive method used, reason for choice, source of information, satisfaction with the contraceptive method. Telephone survey.ResultsA total of 417 women were interviewed. The median age was 30.3 years (SD: 7.7). Spanish 69%, and 82% of participants had secondary or university studies. More than half (57%) were nulliparous. The type of contraceptive used included: progestins only: 14%, combined hormonal contraceptive: 74%, copper IUD: 2%, and condom 10%. The prevalence of use of “progestins-only” was 13.9% (95% CI: 10.6-17.2). Medroxyprogesterone acetate injection was the most progestin-only method used (4.6%), desogestrel oral pill (4.1%), IUD-levonorgestrel IUD (3.9%), and etonogestrel subdermal implant (1.9%). The family doctor was the prescriber in 71% of the women. Satisfaction: high (range 9-10). Using only progestogens was associated with older age, being non-Spanish, breastfeeding, and having a medical contraindication for combined contraception (P < 0.05).ConclusionsThe prevalence of use for progestins was 14%, satisfaction was very high for all contraceptive methods. The user profile for the only progestins-only corresponds to older, and non-Spanish women with conditions such as breastfeeding or contraindications for other contraceptives.     

婴儿喂养形式与产后恢复月经分析

为研究哺乳与哺乳性闭经时间的关系,本文对541对二胎母婴自分娩后7天内至母亲恢复正常月经期间婴儿喂养及相关情况进行了随访研究。结果显示,喂奶次数和时间随产后时间变化不大。产后半年内,婴儿摄食90％以上为母乳,至婴儿一岁,母乳含量仍约70％。开始添加辅食的平均时间为产后153天。产后2周全母乳喂养率为73.4％,产后3月、6月分别约为60％和40％。产后一年半,仍有近80%的母亲部分母乳哺喂孩子。产后61,89,187和369天,母亲恢复月经累计概率分别为0.0150,0.0395,0.2345和0.6820。哺乳性闭经时间平均为282天。结果说明:全母乳喂养和以母乳为主的喂养时间较长和添加辅食较晚的母亲闭经时间较长。产后首次月经的出现是应采用避孕措施的信号。     

Contraceptive use by obese women 1 year postpartum

Background

Obese women have higher rates of pregnancy complications, making the prevention of unintended pregnancies in this group of particular importance.

Study Design

We performed a secondary analysis of data from Active Mothers Postpartum (AMP), a randomized controlled trial aimed at postpartum weight reduction. We assessed contraceptive use among 361 overweight/obese women 12 months postpartum. Logistic regression was used to model the effect of body mass index (BMI) categories on effective contraceptive use (intrauterine, hormonal or sterilization methods) while adjusting for potential confounders including age, race, parity, breastfeeding, education and chronic illness.

Results

Effective contraceptive use was reported by 45% of women. In the multivariable model, women with a BMI ≥35 kg/m² were less likely to use effective contraception than women with a BMI <30 kg/m² (OR 0.5, 95% CI 0.3-0.8). There was a trend towards less use of effective contraception among women with a BMI 30-34.9 kg/m² as compared to women with a BMI <30 kg/m².

Conclusion

At 12 months postpartum, obese women were less likely to use effective contraceptive methods than overweight women. Although certain contraceptive methods may be preferred over others in this population, providers should reinforce the importance of effective contraception to avoid unintended pregnancies in obese women.     

The effect of depot medroxyprogesterone acetate (DMPA) on bone mineral density (BMD) and evaluating changes in BMD after discontinuation of DMPA in Chinese women of reproductive age

Background

Depot medroxyprogesterone acetate (DMPA) as a hormonal contraceptive is highly effective and widely used, but it may reduce bone mineral density (BMD) and increase the risk of osteoporosis. We compared BMD between users of intramuscular DMPA and nonhormonal subjects and evaluated the changes in BMD after discontinuation of DMPA.

Study Design

The study included 68 women aged between 25 and 40 years using DMPA for 24 months and 59 women aged between 25 and 40 years using nonhormonal contraception as nonusers of hormonal contraception. Sixty-one women in the DMPA group and 52 women in the nonusers of hormonal contraception group completed the 2-year post-treatment periods. BMD of the lumbar spine and femoral neck was measured every 12 months for 48 months using dual-energy X-ray absorptiometry, comparing mean BMD changes in DMPA users and discontinuers with nonusers.

Results

At 24 months of treatment, as compared to baseline, the mean BMD of DMPA users in lumbar spine and femoral neck decreased by 5.52% and 6.35%, respectively. Lumbar spine and femoral neck BMD in women who used DMPA significantly decreased compared to the nonusers (p<.001). At 24 months after DMPA discontinuation, the mean BMD values in DMPA users increased significantly. Although the values of the lumbar spine and femoral neck BMD in DMPA users were still 1.08% and 2.30%, respectively, below their baseline values, there were no significant difference when compared to nonusers (p>.05).

Conclusion

These results show that BMD declined during use of DMPA in women aged 25 to 40 years. Bone loss occurring with DMPA use is reversible after DMPA discontinuation.     

Estrogen-free oral hormonal contraception: benefits of the progestin-only pill

Although combined oral contraceptives (COCs) are commonly used and highly effective in preventing pregnancy, they may not be suitable for some women. COC use is associated with increased rates of cardiovascular events and is not recommended in nonbreastfeeding women in the immediate postpartum period or in breastfeeding women during the initial 6 months of breastfeeding. Moreover, estrogen-related adverse effects, such as headache, are common. Estrogen-free progestin-only pills (POPs) are a valuable option in women who prefer to take an oral hormonal contraceptive, but are ineligible for, or choose not to use, COCs. Although some POPs have been associated with lower contraceptive effectiveness than COCs, the POP containing desogestrel has shown similar contraceptive effectiveness to COCs. The most commonly reported complaints in women using all POPs are bleeding problems. Counseling women interested in using POPs about the variable bleeding patterns associated with this method may improve compliance and acceptance.     

Predictors of Breastfeeding in Overweight and Obese Women: Data From Active Mothers Postpartum (AMP)

Excess maternal weight has been negatively associated with breastfeeding. We examined correlates of breastfeeding initiation and intensity in a racially diverse sample of overweight and obese women. This paper presents a secondary analysis of data from 450 women enrolled in a postpartum weight loss intervention (Active Mothers Postpartum [AMP]). Sociodemographic measures and body mass index (BMI), collected at 6 weeks postpartum, were examined for associations with breastfeeding initiation and lactation score (a measure combining duration and exclusivity of breastfeeding until 12 months postpartum). Data were collected September 2004–April 2007. In multivariable analyses, BMI was negatively associated with both initiation of breastfeeding (OR: .96; CI: .92–.99) and lactation score (β −0.22; P = 0.01). Education and infant gestational age were additional correlates of initiation, while race, working full-time, smoking, parity, and gestational age were additional correlates of lactation score. Some racial differences in these correlates were noted, but were not statistically significant. Belief that breastfeeding could aid postpartum weight loss was initially high, but unrelated to breastfeeding initiation or intensity. Maintenance of this belief over time, however, was associated with lower lactation scores. BMI was negatively correlated with breastfeeding initiation and intensity. Among overweight and obese women, unrealistic expectations regarding the effect of breastfeeding on weight loss may negatively impact breastfeeding duration. In general, overweight and obese women may need additional encouragement to initiate breastfeeding and to continue breastfeeding during the infant’s first year.     

Contraceptive method and self-reported HIV status among women in Malawi

ObjectivesWe aimed to describe contraceptive methods used by women in Malawi and determine whether contraceptive use differed by self-reported HIV status. Effective contraception is a primary method of preventing mother-to-child transmission of HIV.Study designAnalysis is based on 12,658 nonpregnant, sexually debuted women ages 15–49 years in the 2010 Malawi Demographic and Health Survey. Analysis was restricted to respondents with contraceptive need (i.e., fecund and did not want a child in the next 12 months) who reported their last HIV test result. We accounted for the two-stage cluster sampling design by applying cluster, stratum and sample weights. We assessed differences in contraceptive method use by HIV status with χ² tests and multivariable logistic regression.ResultsA total of 893 (7.0%) of respondents reported being HIV positive. Use of long-acting reversible contraception (LARC) was low and did not differ between HIV-positive (1.4%) and HIV-negative (1.9%) women [adjusted odds ratio (aOR)=0.7, 95% confidence interval (CI), 0.4–1.4]. HIV-positive women (15.6%) were less likely than HIV-negative women (30.4%) to use progestin-only injectable contraception (aOR, 0.7; 95% CI, 0.5–0.8). Prevalence of female sterilization was higher among HIV-positive women (17.9%) compared to HIV-negative women (9.2%; aOR=1.7; 95% CI, 1.2–2.3).ConclusionsLARC use was low among adult women with contraceptive need in Malawi. HIV-positive women were less likely to report progestin-only injectable use but more likely to report having undergone female sterilization compared to their HIV-negative counterparts. Noncoercive interventions that provide highly effective methods of contraception to HIV-positive women with contraceptive need are valuable methods of vertical transmission prevention in Malawi.ImplicationsContraceptive use differed by self-reported HIV status among adult women with contraceptive need in Malawi. Female sterilization was significantly higher, and use of progestin-only injectables was significantly lower, among HIV-positive women compared to their HIV-negative counterparts. Use of long-acting reversible contraception was low among both HIV-positive and HIV-negative women.     

The extended Theory of Planned Behavior in explaining exclusive breastfeeding intention and behavior among women in Kelantan,Malaysia

BACKGROUND/OBJECTIVESThe purpose of this study is to utilize an extended Theory of Planned Behavior in identifying predictors of exclusive breastfeeding intention and behavior among women in Kelantan, Malaysia.SUBJECTS/METHODSA prospective cohort study was conducted, recruiting pregnant womenthrough two-stage cluster sampling. Their exclusive breastfeeding intention, attitude, perceived norm, perceived behavioral control and past behavior were obtained at baseline through interviewer-guided questionnaire. At one month after delivery, another interview was conducted to determine the two additional variables in the extended theory, which were their postpartum support and breastfeeding difficulty. The behavior, which was the actual duration of exclusive breastfeeding, was obtained from the second follow-up at six months. Pearson correlation and two hierarchical regression analyses were conducted.RESULTSA total of 200 women completed the study follow-up. Their median intended exclusive breastfeeding duration was 4.0 (IQR 5) months, and the median actual duration was 1.0 (IQR 4) month. The Theory of Planned Behavior explained 51.0% of the variance in intention, with perceived behavioral control and attitude were the significant predictors. It also explained 10.0% of the variance in behavior, but the addition of postpartum support and breastfeeding difficulty increased the amount of explained variance in behavior by 6.0%. The significant predictors of exclusive breastfeeding behavior were intention, postpartum support and breastfeeding difficulty.CONCLUSIONThe extended Theory of Planned Behaviorhad a good predictive ability in explaining exclusive breastfeedingintention and behavior. The women''s intention to practice exclusive breastfeeding may be improved by improving their perceived behavioral control and attitude. Providing correct postpartum support and skills to handle breastfeeding difficulties after delivery will improve their exclusive breastfeeding behavior.     

Safety of the etonogestrel-releasing implant during the immediate postpartum period: a pilot study

BackgroundThe effects of etonogestrel (ETG)-releasing contraceptive implant during the immediate postpartum period on maternal safety are unknown.Study designForty healthy women exclusively breastfeeding were randomized to receive either ETG-releasing implant 24–48 h after delivery (n=20) or depot medroxyprogesterone acetate (DMPA group; n=20) at the sixth week postpartum. We measured blood pressure, maternal and neonatal weight, body mass index (BMI; kg/m²), waist circumference (WC), complete blood count, C-reactive protein, interleukin-6, tumor necrosis factor (TNF-alpha), lipid profile, fasting serum glucose and maintenance of exclusive lactation up to the 12th week postpartum.ResultsDecreases in mean maternal weight, BMI (kg/m²) and WC were significantly greater in the ETG-releasing implant group than in the DMPA group during the first 6 weeks postpartum (-4.64±2.71 kg vs. -2.6±2.45 kg mean±SD, p=.017; -1.77±1.06 kg/m² vs. -0.97±0.95 kg/m², p=.026; -15.3±6.72 cm vs. -9.05±5.84 cm, p=.003, respectively). In addition, total cholesterol and HDL, were lower in DMPA users, and TNF-alpha and leukocytes were higher in DMPA users compared to in the implant group, between 6 and 12 weeks after delivery. The newborns of implant users showed a trend towards gaining more weight, as compared with the infants of the DMPA mothers during the first 6 weeks of life (implant group: +1460.50±621.34 g vs. DMPA group: +1035.0±562.43 g, p=.05). The remaining variables, including the duration of exclusive breastfeeding, were similar between the groups.ConclusionThe insertion of ETG-releasing contraceptive implant during the immediate postpartum period was not associated with deleterious maternal clinical effects or with significant maternal metabolic alterations or decreased infant weight gain.     

Breastfeeding Duration and Development of Dysglycemia in Women Who Had Gestational Diabetes Mellitus: Evidence from the GUSTO Cohort Study

(1) Background: Breastfeeding has been shown to support glucose homeostasis in women after a pregnancy complicated by gestational diabetes mellitus (GDM) and is potentially effective at reducing long-term diabetes risk. (2) Methods: Data from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study were analyzed to understand the influence of breastfeeding duration on long-term dysglycemia (prediabetes and diabetes) risk in women who had GDM in the index pregnancy. GDM and dysglycemia four to seven years postpartum were determined by the oral glucose tolerance test (OGTT). A Poisson regression model with a robust error variance was used to estimate incidence rate ratios (IRRs) for dysglycemia four to seven years post-delivery according to groupings of the duration of any breastfeeding (<1, ≥1 to <6, and ≥6 months). (3) Results: Women who had GDM during the index pregnancy and complete breastfeeding information and OGTT four to seven years postpartum were included in this study (n = 116). Fifty-one women (44%) had postpartum dysglycemia. Unadjusted IRRs showed an inverse association between dysglycemia risk and ≥1 month to <6 months (IRR 0.91; 95% confidence interval [CI] 0.57, 1.43; p = 0.68) and ≥6 months (IRR 0.50; 95% CI 0.27, 0.91; p = 0.02) breastfeeding compared to <1 month of any breastfeeding. After adjusting for key confounders, the IRR for the ≥6 months group remained significant (IRR 0.42; 95% CI 0.22, 0.80; p = 0.008). (4) Conclusions: Our results suggest that any breastfeeding of six months or longer may reduce long-term dysglycemia risk in women with a history of GDM in an Asian setting. Breastfeeding has benefits for mothers beyond weight loss, particularly for those with GDM.     

Recovery of bone mineral density following pregnancy and lactation a longitudinal study

OBJECTIVE: The purpose of the study was to examine the recovery of maternal bone mineral density (BMD) following pregnancy and lactation, including the effects of subsequent pregnancy and lactation. SUBJECTS AND METHODS: Twenty-eight pregnant women were followed longitudinally from early pregnancy (baseline) to five years postpartum (maximum). BMD was measured by ultrasonic bone densitometry at early pregnancy, one week postpartum and at a six-month intervals thereafter. Stiffness calculated from the combined value of speed of sound and broadband ultrasound attenuation was used as an index of BMD. Changes in BMD were examined in 19 women without subsequent pregnancy, divided by the period of lactation, 0-1 month (control), 2-6 months and 8 months or longer. Then, the relationship of recovery of BMD to the interval before a subsequent pregnancy was examined. RESULTS AND CONCLUSIONS: 1. BMD in women with 0-1 and 2-6 months lactation duration returned to baseline levels within 1 and 1.5 years postpartum, respectively. That in women with a lactation duration of 8-12 months returned to the baseline within 4 years postlivery after an interval of more than 1 year following weaning showed recovery at subsequent delivery. In some, increase was observed after the period of lactation. 3. BMD in women with subsequent delivery within 1 year after weaning showed an overall decrease at subsequent delivery. These results show that BMD lost during pregnancy and lactation returns to the baseline within four years postpartum, depending on the lactation period, and the length of time from weaning to the next delivery, rather than the lactation period, affect BMD recovery.     

Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio's Medicaid Expansion Under the Affordable Care Act

BackgroundEnsuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio's Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum visit attendance, receipt of contraceptive counseling, and use of contraceptive methods.MethodsWe used Ohio's linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to December 2015) the ACA Medicaid expansion implementation period (N = 170,787 after exclusions). We categorized women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the association of the ACA expansion with their postpartum enrollment in Medicaid and use of services.ResultsWomen who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2 percentage point) increase in the likelihood of long-acting reversible contraceptive use.ConclusionsOhio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.     

Postpartum Contraception Use by Urban/Rural Status: An Analysis of the Michigan Pregnancy Risk Assessment Monitoring System Data

ObjectiveWe sought to examine rural/urban differences in postpartum contraceptive use, which are underexplored in the literature.MethodsWe analyzed phase 5 (2004–2008) of the Michigan Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Using Rural–Urban Commuting Area codes and weighted multinomial logistic regression, we examined the association between self-reported postpartum contraceptive method and rural/urban residence among postpartum women not desiring pregnancy (n = 6,468).ResultsPostpartum (mean, 16.5 weeks after delivery), 14.4% of respondents were using sterilization, 6.7% long-acting reversible contraception (LARC), 37.3% moderately effective hormonal methods, 38.4% less effective methods or no method, and 3.2% abstinence. Multivariable analysis yielded sporadic geographic patterns. Odds of method use varied significantly by age, parity, body mass index, and breastfeeding status. Not discussing contraception with a prenatal healthcare provider decreased odds of postpartum LARC use (odds ratio, 0.52; 95% CI, 0.36–0.75). Number of prenatal visits and weeks since delivery were not associated with postpartum contraception method.ConclusionsWe did not observe strong variation in postpartum contraceptive use based on geography. Low uptake of highly effective contraception across rural and urban areas suggests a need for education and outreach regarding these methods.