Abstract
Objective:
Preliminary findings from selected health systems revealed interruptions in reproductive health care services due to the COVID-19 pandemic. We estimated changes in postpartum contraceptive provision associated with the start of the COVID-19 pandemic in Maine.
Methods:
We used the Maine Health Data Organization’s All Payer Claims Database for deliveries from October 2015 through March 2021 (n = 45 916). Using an interrupted time-series analysis design, we estimated changes in provision rates of long-acting reversible contraception (LARC), permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic. We performed 6- and 12-month analyses (April 2020–September 2020, April 2020–March 2021) as compared with the reference period (October 2015–March 2020). We used Poisson regression models to calculate level-change rate ratios (RRs) and 95% CIs.
Results:
The 6-month analysis found that provision of LARC (RR = 1.89; 95% CI, 1.76-2.02) and moderately effective contraception (RR = 1.51; 95% CI, 1.33-1.72) within 3 days of delivery increased at the start of the COVID-19 pandemic, while provision of LARC (RR = 0.95; 95% CI, 0.93-0.97) and moderately effective contraception (RR = 1.08; 95% CI, 1.05-1.11) within 60 days of delivery was stable. Rates of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased. RRs from the 12-month analysis were generally attenuated.
Conclusion:
Disruptions in postpartum provision of permanent contraception occurred at the beginning of the COVID-19 pandemic in Maine. Public health policies should include guidance for contraceptive provision during public health emergencies and consider designating permanent contraception as a nonelective procedure.
Keywords: contraception, long-acting reversible contraception (LARC), permanent contraception, postpartum, COVID-19
Equitable access to contraception is an essential component of public health and warrants ongoing evaluation and planning by government and public health entities. Unintended pregnancies and short interpregnancy intervals (the time from the end of one pregnancy to the start of the next; hereafter, “short-interval pregnancies”) are associated with poor health outcomes for postpartum people and infants.1-4 Timely initiation of effective postpartum contraception is an important tool to reduce the rates of unintended and short-interval pregnancies and improve maternal and infant health outcomes.2,5 Furthermore, barriers to accessing preferred methods of contraception impede reproductive autonomy; therefore, it is imperative that regulatory agencies and health care systems prioritize access to contraceptives. 6 Postpartum people should have access to the full range of contraceptive methods to meet their reproductive health care needs, including highly effective methods such as long-acting reversible contraception (LARC) and female permanent contraception (eg, tubal ligation). LARC has been shown to substantially reduce unintended and short-interval pregnancies.2,7 Thus, the American College of Obstetricians and Gynecologists (ACOG) recommends that immediate postpartum LARC be discussed during prenatal contraceptive counseling and available to all patients.2,8,9 Female permanent contraception is one of the most effective forms of contraception, and ACOG recommends that postpartum people have the opportunity to access these contraceptive procedures, which ACOG designates as nonelective. 10
Following national recommendations aimed at reducing the spread of COVID-19, most states issued executive orders in March 2020 that included the postponement of elective and nonurgent medical procedures and outpatient visits, as well as a stay-at-home order and health insurance mandates to cover telehealth visits. In April 2020, frameworks for determining which services could be delayed were released by the Centers for Medicare & Medicaid Services; however, guidance on reproductive health care services was not included.11,12 Concern that pandemic countermeasures may have negatively affected access to reproductive health services, including designation of reproductive health procedures as elective or nonurgent, was expressed by the reproductive health community early in the pandemic.13-16 Indeed, a national survey conducted by the Guttmacher Institute during April 30–May 6, 2020, found that 1 in 3 women had difficulty accessing reproductive health care or contraception because of the COVID-19 pandemic. 16
Findings vary on the extent to which provision of postpartum contraception was disrupted by the COVID-19 pandemic. Decreases in provision of female permanent contraception and/or LARC at the start of the pandemic have been noted in data from commercial health plans from Michigan, in a nationwide sample of multipayer claims, and at a teaching hospital in Illinois.17-19 In addition, a shift toward immediate postpartum LARC insertions and away from outpatient LARC insertions was reported by a single academic medical center in Washington, DC. 20 However, to our knowledge, no study has yet examined population-level state data or the provision of postpartum contraception in a largely rural state such as Maine. Rural populations may be more vulnerable than urban populations to disruptions in reproductive health care service because of barriers in accessing care, such as decreased availability of obstetric and family planning clinicians, increased travel time to hospitals and appointments, and higher rates of poverty and use of public health insurance. 21
The objective of our analysis was to estimate changes in provision of postpartum contraception at the start of the COVID-19 pandemic in Maine by using an interrupted time-series analysis design with 6- and 12-month follow-up periods. We anticipated that changes might have occurred in contraception provision after implementation of emergency measures in Maine, which may have introduced barriers to reproductive health care.
Methods
Data
We used the Maine Health Data Organization’s All Payer Claims Database for this analysis. In addition to all-payer claims for hospital inpatient and outpatient visits, these data include claims paid for Maine residents by public payers and private insurers for private physician visits, clinic visits, and prescription claims, as required by state statute and rules.22,23 We analyzed claims data from patients aged 16-55 years who delivered from October 2015 (the start of International Classification of Diseases, Tenth Revision, Clinical Modification codes in the United States) through March 2021 (the latest month of complete data available at the time of the analysis). We identified deliveries using a code list for live births and stillbirths published by the Alliance for Innovation on Maternal Health 24 that we augmented by adding delivery-related Current Procedural Terminology (CPT) codes. We excluded stillbirth deliveries from our analysis because people experiencing stillbirth may have unique postpartum contraception needs and there is currently no recommended minimum interpregnancy interval following a stillbirth. 25
We determined delivery dates by using an algorithm developed by our team, which preferentially used service dates of delivery-related CPT codes from professional claims rather than those from delivery-related facility claims, which capture hospitalization service dates, not necessarily delivery dates. We identified approximately 90% of delivery dates by using CPT code service dates, and we identified the remaining 10% by using service dates for other delivery-related claims. We characterized health insurance type by using the payer for the delivery-related claims and identified cesarean section delivery by using diagnosis and procedure codes. We determined rural versus urban residency according to the zip code at the time of delivery by using the US Department of Agriculture rural–urban commuting area codes, which classify census tracts based on population density, urbanization, and daily commuting patterns. 26 We categorized these codes into rural (large rural, small rural, and isolated rural) and urban (core metropolitan, small metropolitan) per a classification scheme developed by the New England Rural Health Association.26,27
The institutional review board at the University of Southern Maine determined this study to be exempt from human subjects review because it used secondary data through a data use agreement.
Outcomes
Our primary outcomes were rates of provision of postpartum contraception within 3 and 60 days of delivery. We measured provision within 3 days to capture immediate postpartum provision prior to hospital discharge and within 60 days to capture provision from delivery through the first postpartum visit. We based these measures on a contraceptive care performance measure published and maintained by the US Office of Population Affairs and used by the Centers for Medicare & Medicaid Services. 28 This measure categorizes contraceptive methods as the following: LARC (intrauterine devices, implants), female permanent contraception (bilateral tubal ligation or salpingectomy, also known as female sterilization), and moderately effective contraceptive methods (injectables, oral pills, patch, ring, or diaphragms).
Statistical Analysis
Interrupted time-series model
Using an interrupted time-series analysis design,29,30 we estimated changes in rates of provision of postpartum contraception after the start of the COVID-19 pandemic. We performed 2 sets of analyses: a 6-month analysis to estimate the immediate effects at the start of the pandemic and a 12-month analysis to estimate longer-term effects (eFigure1 in Supplemental Material). A civil state of emergency went into place in Maine in mid-March 2020, which included guidance to postpone elective procedures and medical appointments; a stay-at-home directive was issued on March 31, 2020. 31 April 2020 was the first full month after these countermeasures were in place; therefore, our postpandemic cohorts were April–September 2020 for the 6-month analysis and April 2020–March 2021 for the 12-month analysis. We used the prepandemic cohort, October 2015–March 2020, as the reference group for both analyses.
We aggregated data by delivery month, with the number of women with live births as the denominator and the number of women with each contraception provision type as the numerator. We included diaphragm as a moderately effective method to be consistent with measures from the Office of Population Affairs. We counted multiple live births (eg, twins) to the same woman once. We used Poisson regression models, offset for the number of women with live births and with robust SEs to correct for autocorrelation, to calculate rate ratios (RRs) and 95% CIs for the level change (ie, jump) at the start of the pandemic as well as the slope change (ie, change in trends) after the start of the pandemic. We calculated smoothed rates for April 2020 (the first month after the start of the pandemic) based on observed data in the postpandemic cohort and compared those rates with predicted rates for April 2020 based on prepandemic data, assuming that no pandemic had occurred. The level-change RR corresponds to the smoothed rates for April 2020 divided by the predicted rates for April 2020.
We examined seasonal trends in postpartum provision of contraception and found no abrupt changes through visual inspection. We also reviewed Maine Medicaid’s contraception policies 32 to ensure that no changes coincided with the start of the COVID-19 pandemic.
Model fit and sensitivity analysis
We fit linear and quadratic models and assessed goodness of fit using the quasi-likelihood under independence model criterion. Because linear models were generally a better fit to the data, we used these models for our analysis. For a sensitivity analysis, we repeated the analysis excluding the month of March 2020 to assess whether findings changed when we treated this month as a transition month.
Subgroup and post hoc analysis
We performed a subgroup analysis by rural versus urban residency at the time of delivery. Maine has the highest percentage of residents living in a rural area in the United States, 33 and unique barriers to access in care are experienced by rural communities, which may increase the risk of adverse maternal and infant health outcomes related to unintended and short-interval pregnancies.25,34
After reviewing preliminary results, we conducted a post hoc analysis to identify changes in permanent contraception by payer among patients who delivered by cesarean section. We conducted this analysis because we found that most 3-day permanent contraception procedures, in the pre- and postpandemic cohorts, occurred among patients who delivered via cesarean section (82%). We used SAS version 9.4 (SAS Institute) for analysis.
Results
We included 45 916 deliveries in the study: 38 219 in the pre–COVID-19 cohort (October 2015–March 2020) and 7697 in the 12-month post–COVID-19 cohort (April 2020–March 2021). Characteristics of the 2 cohorts were similar (Table 1).
Table 1.
Characteristics of deliveries before and after the start of the COVID-19 pandemic, Maine a
| Characteristic | Before COVID-19 pandemic (October 2015–March 2020) | After start of COVID-19 pandemic (April 2020–March 2021) |
|---|---|---|
| Total deliveries, no. | 38 219 | 7697 |
| Mean age, y | 29.1 | 29.6 |
| Health insurance type, no. (%) | ||
| Medicaid | 21 740 (56.9) | 4429 (57.5) |
| Commercial | 16 427 (43.0) | 3256 (42.3) |
| Cesarean section, no. (%) | 11 195 (29.3) | 2342 (30.4) |
| Residence type, b no. (%) | ||
| Rural | 24 425 (63.9) | 4977 (64.7) |
| Urban | 13 618 (35.6) | 2703 (35.1) |
| Missing | 0 | 17 (0.2) |
Data source: Maine Health Data Organization’s All Payer Claims Database. 22
During October 2015–March 2021, the average provision rates of LARC, female permanent contraception, and moderately effective methods within 3 days were 9.5, 65.4, and 15.5 per 1000 deliveries, respectively; corresponding provision rates within 60 days were 153.2, 74.7, and 224.4 per 1000 deliveries. Use of individual contraceptive methods in the pre- and postpandemic cohorts can be found in eTable 1 in Supplemental Material. Diaphragm use accounted for <0.1% of contraceptive methods before and after the start of the pandemic.
6-Month Analysis: April–September 2020
We found immediate increases in the rate of provision of LARC within 3 days (RR = 1.89; 95% CI, 1.76-2.02), and the rate of provision of LARC within 60 days was stable (RR = 0.95; 95% CI, 0.93-0.97) (Figure 1, Table 2). The rate of provision of moderately effective contraception within 3 days increased immediately after the start of the COVID-19 pandemic (RR = 1.51; 95% CI, 1.33-1.72), and that within 60 days was stable (RR = 1.08; 95% CI, 1.05-1.11) (eFigure 2 in Supplemental Material, Table 2). The rate of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased immediately after the start of the pandemic (Figure 2, Table 2). Slope changes (change in trends) after the start of the pandemic were generally slight, except for provision of LARC within 3 days, which changed from an increasing slope before the start of the pandemic to a decreasing slope after the start of the pandemic (eTable 2 in Supplemental Material).
Figure 1.
Monthly rates of long-acting reversible contraception (LARC) provision within 3 days of delivery before and after the start of the COVID-19 pandemic, Maine, October 2015–September 2020. Shading indicates 95% confidence bands for smoothed rates before and after the pandemic. Dashed vertical line indicates the start of the pandemic in March 2020. Data source: Maine Health Data Organization’s All Payer Claims Database. 22
Table 2.
Changes in rates (per 1000 deliveries) of LARC, female permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic, Maine a
| 6-month analysis | 12-month analysis | |||||
|---|---|---|---|---|---|---|
| Type of contraception | Level change, RR (95% CI) | Predicted rate for April 2020 b | Smoothed rate for April 2020 c | Level change, RR (95% CI) | Predicted rate for April 2020 b | Smoothed rate for April 2020 c |
| LARC | ||||||
| Within 3 d of delivery | 1.89 (1.76-2.02) | 10.9 | 20.5 | 1.57 (1.31-1.87) | 11.6 | 18.2 |
| Within 60 d of delivery | 0.95 (0.93-0.97) | 161.1 | 153.1 | 1.04 (1.01-1.08) | 156.4 | 163.3 |
| Permanent contraception | ||||||
| Within 3 d of delivery | 0.70 (0.63-0.78) | 71.2 | 49.9 | 0.90 (0.81-0.99) | 66.1 | 59.1 |
| Within 60 d of delivery | 0.71 (0.63-0.80) | 80.8 | 57.2 | 0.91 (0.80-1.03) | 74.8 | 67.9 |
| Moderately effective d | ||||||
| Within 3 d of delivery | 1.51 (1.33-1.72) | 15.1 | 22.8 | 1.60 (1.40-1.83) | 14.8 | 23.7 |
| Within 60 d of delivery | 1.08 (1.05-1.11) | 218.5 | 235.3 | 1.02 (0.99-1.05) | 222.0 | 226.4 |
Abbreviations: LARC, long-acting reversible contraception; RR, rate ratio.
Data source: Maine Health Data Organization’s All Payer Claims Database. 22
Assuming no pandemic.
Based on observed data.
Moderately effective methods include injectables, pill, patch, ring, and diaphragm.
Figure 2.
Monthly rates of female permanent contraception provision within 3 days of delivery before and after the start of the COVID-19 pandemic, Maine, October 2015–September 2020. Shading indicates 95% confidence bands for smoothed rates before and after the pandemic. Dashed vertical line indicates the start of the pandemic in March 2020. Data source: Maine Health Data Organization’s All Payer Claims Database. 22
12-Month Analysis: April 2020–March 2021
When compared with the results of the 6-month analysis, level- and slope-change RRs in the 12-month analysis were attenuated (Table 2; eTable 2 in Supplemental Material; eFigures 3-5 in Supplemental Material).
Rural–Urban Subgroup Analysis
In our 6-month analysis by rural versus urban residence, we found that rates of provision of 3-day LARC and 3-day moderately effective contraception were higher for rural residents than for urban residents and that changes in rates of provision of 3-day permanent contraception were similar (Table 3; eTable 3 in Supplemental Material). In the 12-month analysis, estimates for provision of LARC within 3 days were similar between rural and urban residents, but provision of moderately effective contraception within 3 days was higher among rural than among urban residents.
Table 3.
Changes in rates (per 1000 deliveries) of LARC, female permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic, stratified by urban and rural residence, Maine a
| 6-month analysis | 12-month analysis | |||||
|---|---|---|---|---|---|---|
| Outcome by subgroup | Level change, RR (95% CI) | Predicted rate for April 2020 b | Smoothed rate for April 2020 c | Level change, RR (95% CI) | Predicted rate for April 2020 b | Smoothed rate for April 2020 c |
| LARC | ||||||
| Within 3 d of delivery | ||||||
| Urban | 1.62 (1.41-1.86) | 18.3 | 29.7 | 1.58 (1.28-1.93) | 18.4 | 29.0 |
| Rural | 2.34 (2.11-2.60) | 6.7 | 15.6 | 1.51 (1.21-1.88) | 7.9 | 11.9 |
| Within 60 d of delivery | ||||||
| Urban | 0.93 (0.89-0.98) | 178.8 | 167.1 | 1.08 (0.98-1.19) | 171.2 | 185.0 |
| Rural | 0.96 (0.94-0.98) | 151.1 | 144.6 | 1.02 (0.99-1.06) | 147.7 | 151.1 |
| Female permanent contraception | ||||||
| Within 3 d of delivery | ||||||
| Urban | 0.76 (0.65-0.90) | 49.7 | 38.0 | 0.93 (0.76-1.12) | 47.1 | 43.7 |
| Rural | 0.69 (0.63-0.76) | 82.7 | 57.2 | 0.89 (0.82-0.97) | 76.4 | 68.1 |
| Within 60 d of delivery | ||||||
| Urban | 0.81 (0.67-0.97) | 55.1 | 44.4 | 0.95 (0.72-1.24) | 52.4 | 49.7 |
| Rural | 0.69 (0.62-0.76) | 94.6 | 65.1 | 0.90 (0.83-0.99) | 86.9 | 78.5 |
| Moderately effective method d | ||||||
| Within 3 d of delivery | ||||||
| Urban | 1.37 (1.19-1.58) | 18.9 | 25.8 | 1.37 (1.12-1.67) | 19.2 | 26.2 |
| Rural | 1.64 (1.42-1.88) | 13.0 | 21.2 | 1.76 (1.55-2.00) | 12.6 | 22.2 |
| Within 60 d of delivery | ||||||
| Urban | 1.19 (1.13-1.24) | 192.6 | 228.8 | 1.07 (0.99-1.16) | 198.0 | 212.7 |
| Rural | 1.02 (1.00-1.05) | 233.6 | 239.2 | 0.99 (0.96-1.03) | 235.9 | 234.2 |
Abbreviations: LARC, long-acting reversible contraception; RR, rate ratio.
Data source: Maine Health Data Organization’s All Payer Claims Database. 22
Assuming no pandemic.
Based on observed data.
Moderately effective methods include injectables, pill, patch, ring, and diaphragm.
Post Hoc and Sensitivity Analysis
In our post hoc analysis of changes in rates of permanent contraception among cesarean sections by payer type, we found a decrease after the start of the pandemic for deliveries that Medicaid paid for (RR = 0.60; 95% CI, 0.51-0.71) but not for deliveries that commercial health insurance paid for (RR = 1.08; 95% CI, 0.97-1.21) (eFigure 6 in Supplemental Material). Our sensitivity analysis excluding March 2020 resulted in RR estimates for level change and slope change within ±10% of the primary analysis.
Discussion
After the start of the COVID-19 pandemic in Maine, we found abrupt increases in the provision of LARC and moderately effective contraception within 3 days of delivery and decreases in the provision of female permanent contraception. These findings were fairly robust to our use of 6- and 12-month analyses, which captured the immediate and longer-term effects of the pandemic on postpartum contraception provision.
The increase in rates of provision of LARC within 3 days of delivery may reflect patient and/or clinician anticipation of delayed in-person postpartum visits, with immediate postpartum LARC selected as an expedited alternative. In addition, given that LARC provision rates within 60 days postpartum did not change after the start of the pandemic, the increased rates found for that within 3 days may represent a shift from outpatient to inpatient provision. Similarly, while we found an increase in provision rates of moderately effective contraception within 3 days, we found no change within 60 days postpartum. This increase could represent an attempt to bridge women with moderately effective contraception while awaiting a more effective method to be provided at a later visit, or it may reflect concerns about delays of in-person postpartum visits; it could also represent patients’ increased preference for these types of contraceptive methods during the start of the pandemic. As with LARC, the findings of a null provision rate for moderately effective contraception within 60 days may indicate a shift from outpatient to inpatient provision.
The decrease in permanent contraception within 3 days could be due to policies in place in Maine at the start of the COVID-19 pandemic, which did not designate permanent contraception procedures as nonelective and could have resulted in canceled or postponed procedures. Because this decrease appeared to be primarily among people with Medicaid, it could also be due to the pandemic disrupting patients’ ability to complete the Consent for Sterilization form at least 30 days before the procedure date, which is required for Medicaid but not for commercial health insurance. 14 The decrease in provision rates within 60 days for permanent contraception were the same as the rates within 3 days because tubal ligations are unlikely to be scheduled between hospital discharge and 60 days postpartum, which is a time of physical recovery from the delivery.
We found little difference in rates of provision of contraceptive method based on rurality of maternal residence zip code; this finding implies that adaptations to routine care were seen across the health care spectrum and may have similarly affected postpartum rural and urban residents in Maine.
Our findings were generally attenuated in the 12-month analysis, which suggests that the changes in provision of contraception at the start of the pandemic were transient when examined with a longer view. Nonetheless, concerns remain about barriers to accessing permanent contraception at the start of the pandemic. Reproductive health care, including abortion, contraception, and fertility services, have historically been designated as elective and nonurgent, and this designation was reflected in several state policies and guidelines during the pandemic, most notably for abortion care.13-15,35 However, most states, including Maine, provided no guidance for which procedures and services fell under the designation of elective or nonessential services. Without clear guidance from federal agencies or state governments, these determinations were left to individual health systems and facilities.
Strengths and Limitations
This analysis had several limitations. First, claims data do not allow for assessment of patient preferences or reasons for use or nonuse of certain contraceptive methods. Second, these data do not include sociodemographic information, such as race and ethnicity and educational attainment, 22 which are associated with type of contraceptive method provision but were unlikely to change substantially during the study period and bias our results. Third, the data that we used also excluded patients without health insurance, who are less likely than insured patients to attend visits for postpartum contraceptive and outpatient health care; however, these patients represent a small fraction of pregnant people (ie, 7% in a 2016 national study 36 ). Fourth, the data that we used omitted claims related to substance use disorder, in response to a regulation from the Substance Abuse and Mental Health Services Administration. 22 This redaction removes a subset of the postpartum population that may have unique contraceptive needs, and it is unknown how omission of these observations affected our study’s estimates. Approximately 35 per 1000 women delivering in Maine in 2018 had opioid use disorder, 37 so at least 3.5% of deliveries were likely missing from our analysis. Fifth, we could have used a more granular time scale or alternative time scale for our analysis (eg, midmonth to midmonth, as the emergency measures in Maine began in mid-March 2020). The greatest strength of our study was our use of a comprehensive claims database, which captured data on contraception provision at inpatient and outpatient encounters, in private physicians’ offices and clinics, and through pharmacy claims.
Conclusions
Contraception provision is essential and time sensitive, and barriers to its access result in loss of personal and family rights related to reproductive choice. 16 Additionally, poor health outcomes as a consequence of unintended and short-interval pregnancies can have long-standing effects for individuals, families, and communities. 1 Our analysis suggests that disruptions in permanent contraception occurred because of the COVID-19 pandemic and the emergency measures put in place to decrease virus transmission. Further research is warranted to examine potential disparities in access to permanent contraception by payer source. In the future, federal agencies could consider including guidance on which reproductive health care services are essential and designating postpartum permanent contraception as a nonelective procedure to help reduce barriers to access during public health emergencies.
Supplemental Material
Supplemental material, sj-docx-1-phr-10.1177_00333549231170198 for Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine by Catherine Gelsinger, Kristin Palmsten, Heather S. Lipkind, Mariah Pfeiffer, Christina Ackerman-Banks, Jennifer A. Hutcheon and Katherine A. Ahrens in Public Health Reports
Acknowledgments
The authors thank the Maine Health Data Organization, which is responsible for the State of Maine’s All Payer Claims Database. We used the Maine Health Data Organization’s All Payer Claims Database for this analysis as authorized under data request 2021040501.
Footnotes
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.P. has research contracts with AbbVie, GSK, and Sanofi that are unrelated to the current study.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this article was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award R15HD101793. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
ORCID iD: Catherine Gelsinger, RN 
https://orcid.org/0000-0001-9845-6476
Supplemental Material: Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th Edition.
Data Sharing: Because of the sensitive nature of the data collected for this study, requests to access the dataset from qualified researchers trained in human subjects confidentiality protocols may be sent to Maine Health Data Organization at https://mhdo.maine.gov/tableau/data.cshtml
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Associated Data
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Supplementary Materials
Supplemental material, sj-docx-1-phr-10.1177_00333549231170198 for Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine by Catherine Gelsinger, Kristin Palmsten, Heather S. Lipkind, Mariah Pfeiffer, Christina Ackerman-Banks, Jennifer A. Hutcheon and Katherine A. Ahrens in Public Health Reports