Introduction
Patients with opioid use disorder (OUD) have lower rates of receiving postpartum contraception, especially highly-effective methods, than patients without OUD.1 Pregnant patients with a consistent plan for a postpartum contraceptive method (PCM) between prenatal care and hospital discharge after delivery are more likely to choose highly effective methods of contraception, though it is unclear whether this holds true for patients with OUD.2 Given disparities in rates of postpartum contraception for patients with OUD, we sought to determine the relationship between consistency of planned PCM and effectiveness of chosen PCM for patients with OUD.
Materials and Methods
This is a secondary analysis of a retrospective cohort study of 8,654 patients delivering at an urban tertiary care institution between 2012-2014. Full methodologic details have been previously published.3 Briefly, data were abstracted from the outpatient and inpatient linked electronic medical record for every person delivering at or beyond 20 weeks’ gestation up to one year after delivery. Choice of PCM was defined as last method documented during prenatal care, delivery admission, and at the outpatient postpartum visit. This secondary analysis includes only those patients with OUD, identified by documentation during the pregnancy. Patients without prenatal documentation of PCM were excluded from this analysis. Planned PCM was categorized into tiers based on efficacy – highly effective (permanent and long acting reversible contraception), moderately effective (injectables, pills, patch, ring, diaphragm), least effective (barrier, fertility awareness, withdrawal, and abstinence), and none.4 Our key predictor for this analysis was consistency which was defined as choosing the same tier of efficacy during prenatal care and at time of hospital discharge after delivery. Demographic and clinical characteristics were compared between patients with and without a consistent PCM plan using chi-square, t-test, or Mann-Whitney test as appropriate. Differences in outcomes including tier of efficacy for planned PCM, plan fulfillment within 90 days postpartum, postpartum visit attendance, and subsequent pregnancy within 365 days of the index delivery were calculated using chi-square analyses. Ninety days was chosen to allow for fulfillment of an interval permanent contraception surgery, placement of an outpatient long-acting reversible contraceptive device, and service recovery in the case of a missed postpartum appointment.
Results
Of the 200 eligible patients, 89 (44.5%) had a consistent planned PCM (Table 1). Patients with a consistent planned PCM were more likely to have received adequate prenatal care (p=0.008); otherwise there were no other clinical or demographic differences. There were differences in tier of PCM chosen between the two groups (p<0.001). Patients with a consistent plan tended to be more likely to pick a highly effective method of contraception (39.3% vs 27.9%) or decline postpartum contraception (46.1% vs 9%), and tended to be less likely to pick a moderately effective method (13.5% vs 60.4%) than those without consistent plans. There were no differences in PCM fulfillment, postpartum visit attendance, or subsequent pregnancy within 365 days between groups.
Table 1:
Demographic characteristics and contraceptive outcomes for women with consistent versus not consistent postpartum contraceptive plans
| Not consistent | Consistent | p | |
|---|---|---|---|
| n | 111 | 89 | |
| Maternal age at delivery | 27.70 (4.64) | 28.25 (4.34) | 0.397 |
| Parity | 0.322 | ||
| 0 | 37 (33.3) | 21 (24.7) | |
| 1 | 37 (33.3) | 28 (32.9) | |
| 2+ | 37 (33.3) | 36 (42.4) | |
| Gestational age at delivery | 37.67 (3.05) | 38.29 (2.37) | 0.121 |
| Adequate prenatal care | 72 (66.7) | 71 (84.5) | 0.008 |
| Route of Delivery | 0.604 | ||
| Cesarean section | 25 (22.5) | 24 (28.2) | |
| Operative vaginal delivery | 4 ( 3.6) | 2 ( 2.4) | |
| Spontaneous vaginal delivery | 82 (73.9) | 59 (69.4) | |
| Insurance | 0.888 | ||
| Medicaid | 95 (90.5) | 65 (90.3) | |
| Medicare | 6 ( 5.7) | 5 ( 6.9) | |
| None | 4 ( 3.8) | 2 ( 2.8) | |
| Race | 0.586 | ||
| White | 48 (49.0) | 42 (53.8) | |
| Black/African American | 44 (44.9) | 29 (37.2) | |
| Asian | 3 ( 3.1) | 2 ( 2.6) | |
| Other | 3 ( 3.1) | 5 ( 6.4) | |
| Married | 19 (17.1) | 24 (28.9) | 0.075 |
| Attended College | 30 (28.3) | 30 (37.5) | 0.242 |
| Planned method of contraception at hospital discharge | <0.001 | ||
| Highly effective a | 31 (27.9) | 35 (39.3) | |
| Moderately effective b | 67 (60.4) | 12 (13.5) | |
| Less effective c | 3 (2.7) | 1 (1.1) | |
| None | 10 (9.0) | 41 (46.1) | |
| Contraceptive plan fulfilment | 72 (64.9) | 64 (75.3) | 0.16 |
| Postpartum visit attendance | 70 (63.1) | 56 (65.9) | 0.80 |
| Short interval pregnancy | 33 (29.7) | 18 (20.2) | 0.17 |
Presented as n (%) or mean (SD)
permanent contraception and long acting reversible contraception
injectables, pill, patch, and vaginal ring
barrier, fertility awareness, withdrawal, and abstinence
Discussion and Conclusions
In our secondary analysis, almost half of patients with OUD who had a consistent plan desired no contraception. Patients with OUD had a higher rate of a consistent plan for PCM when compared to the original total cohort of 8,654 patients (31.5%).2 While in the original cohort, consistency was linked with an increased likelihood of choosing a highly effective PCM; in this subgroup of patients with OUD, consistency was linked to declining contraception. This increased reliance on no method of contraception may contribute to the increased rate of unintended pregnancies in patients with OUD.5 Frequent reasons for choosing to not use contraception in the general population include low perception of risk of pregnancy, knowledge limitations, and lack of long-term access to healthcare professionals, though this has been largely not studied in patients with OUD. Patients with adequate prenatal care were more likely to have consistent plans which may be a result of increased opportunities to discuss postpartum contraception antenatally. Limitations of our study include limitations in our inferences and ability to provide patient-level data regarding decision-making given the methodology. Further, existing stigma against patients with OUD may prevent patients from seeking prenatal care or disclosing use, which likely impacts our results. Patients with OUD may benefit from comprehensive, longitudinal, and non-coercive contraceptive counseling during prenatal care.
Funding Disclosure:
Dr. Arora is funded by 1R01HD098127 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) branch of the National Institutes of Health (NIH). This work was also funded by the Clinical and Translational Science Collaborative of Cleveland, KL2TR0002547 from the National Center for Advancing Translational Sciences (NCATS) component of the National Institutes of Health and NIH roadmap for Medical Research. This manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Footnotes
The authors report no conflicts of interest.
Other Disclosures/ Conflicts of Interests – None
Presented at Society of Maternal Fetal Medicine 41st Annual meeting, virtual, January 29, 2021
References
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