Abstract
Objective
To determine if postpartum contraceptive choices by primiparous women differ by ethnicity.
Study design
Retrospective nested cohort study analyzing women's characteristics and contraceptive choice.
Results
Of 652 participants, 312 (47.8%) were Hispanic, 287 (44.0%) were non-Hispanic white and 53 (8.1%) were American Indian (AI). Ethnic groups did not vary in choice of intrauterine devices (IUD), implant or pills. In multivariate analysis, depot medroxyprogesterone acetate (DMPA) choice was related to AI (OR 15.28, CI 4.49 – 52.04) and Hispanic ethnicity (OR 3.44, CI 1.12 – 10.58).
Conclusion
Contraceptive choice did not vary between ethnic groups for most methods. DMPA use was higher among Hispanic and AI women.
Keywords: American Indian, contraception, Hispanic, Ethnicity, primiparous
INTRODUCTION
Despite the range of contraceptive methods available in the United States (US), 49% of pregnancies are unintended and 33% have short inter-pregnancy intervals (1, 2). Adverse maternal and infant outcomes occur more frequently among minority and low-income women (3-5). Healthy People 2020 goals aim to reduce the proportion of unintended pregnancies and short inter-pregnancy intervals (1). The prenatal and postpartum period is ideal for contraceptive counseling and initiation (6). Understanding factors that influence postpartum contraceptive choice, initiation and adherence could inform strategies to reduce unplanned and rapid repeat pregnancy. Few studies have examined the role of ethnicity in choice of contraception. The objective of this study is to evaluate whether postpartum contraceptive choice in low risk primiparous women varies by ethnicity.
MATERIALS AND METHODS
This retrospective nested cohort study used data from the Alterations in the Pelvic Floor in Pregnancy, Labor and Ensuing Years (APPLE) study. A prospective cohort study, APPLE was designed to investigate pelvic floor changes following birth in low risk nulliparous women. Participants were recruited from the maternity care services at the University of New Mexico (UNM) Hospital in Albuquerque from 2006-2011. Eligibility criteria for the parent study included: age ≥ 18, ability to speak and read English or Spanish, and singleton gestation. The UNM Human Research Protections Office approved the study.
Data for this study were abstracted from medical records and included demographic characteristics, choice of contraceptive method prior to hospital discharge, and factors affecting contraceptive choice. Ethnicity was self-selected from a pre-defined list including non-Hispanic white (NHW), Hispanic, American Indian (AI), Asian/Pacific Islander, and Black. Contraceptive method choice included intrauterine device (IUD), implant, depomedroxyprogesterone acetate (DMPA), oral contraceptive pills (OCP), patch, ring, condoms and natural family planning. No patients obtained tubal ligations.
We conducted a power analysis based on the anticipated parent sample size of 765 with the assumption that 62% of postpartum women report using effective contraception (7). This study can detect a 17% difference in postpartum contraceptive choice between NHW and Hispanic women with 80% power and α = 0.05.
Statistical analyses
Differences in patient characteristics were compared by one-way ANOVA for continuous variables and chi-square or Fisher's exact test for categorical variables. Stepwise logistic regression identified predictors affecting contraceptive choice. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Data was analyzed using SAS® statistical software (version 9.3, SAS Institute Inc., Cary, NC, USA).
RESULTS
A total of 782 women were recruited for the parent study. 130 women did not meet study criteria and were excluded. Asian/Pacific Islander and Black women were also excluded (n=44) leaving 652 in the final analysis. Overall, 312 (47.8%) were Hispanic, 287 (44.0 %) were NHW and 53 (8.1%) were AI. About 92% of women had a plan for contraception before discharge from the hospital.
Comparatively NHW women were older, married or cohabitating, educated, with private insurance (p<0.001). Hispanic women were more likely to report an unplanned index pregnancy (p = 0.04). AI women were single, had Medicaid and least likely to initiate prenatal care early or have completed college (p<0.001) (Table 1).
Table 1.
Demographic Characteristics and Contraceptive Choice by ethnicity
| Characteristics | Total Population N = 652 | Ethnicity |
P value | Post Hoc Testing | ||
|---|---|---|---|---|---|---|
| Non-Hispanic White (NHW) (N =287) | Hispanic (H) (N =312) | American Indian (AI) (N = 53) | ||||
| Age (years ± SD) | 24.8 ± 5.5 | 26.4 ± 5.4 | 23.6 ± 5.1 | 23.4 ± 5.8 | <0.001 | NHW>H&AI |
| BMI ≥ 25 | 3061 (47.6) | 1171 (40.8) | 1581 (50.6) | 311 (58.5) | 0.007 | H&AI>NHW |
| Parity2 | ||||||
| EAB/SAB/Ectopic | 223 (34.2) | 100 (34.8) | 110 (35.3) | 13 (24.5) | 0.30 | |
| Married/cohabitating2 | 4351 (66.7) | 2181 (76.0) | 1931 (61.8) | 241 (45.3) | < 0.001 | NHW>H&AI |
| ≥ 4 year college education2 | 1891 (29.0) | 1311 (45.6) | 541 (17.3) | 41 (7.5) | <0.001 | NHW>H>AI |
| ≥ 12 prenatal visits2 | 3101 (47.5) | 1531 (53.3) | 1431 (45.8) | 141 (26.4) | <0.001 | NHW>H>AI |
| Unplanned Pregnancy2 | 309 (47.4) | 123 (42.9) | 164 (52.6) | 22 (41.5) | 0.04 | H>NHW |
| Early Prenatal Care2 | 4871 (74.7) | 2351 (81.9) | 2271 (72.8) | 251 (47.2) | <0.001 | NHW>H>AI |
| Antenatal smoking2 | 521 (7.9) | 331 (11.5) | 171 (5.4) | 21 (3.8) | 0.01 | NHW>H&AI |
| Breastfeeding2 | 5741 (88.0) | 2571 (89.5) | 2731 (87.5) | 441 (83.0) | 0.46 | |
| Contraception plan2 | 5991 (91.9) | 2611 (90.9) | 2881 (92.3) | 461 (86.8) | 0.78 | |
| Insurance at delivery2 | ||||||
| - Private | 1911 (29.3) | 1221 (42.5) | 641 (20.5) | 51 (9.4) | <0.001 | NHW>H&AI |
| - Medicaid | 3941 (60.4) | 1371 (47.7) | 2101 (67.3) | 471 (88.7) | <0.001 | AI>H>NHW |
| - Military | 371 (5.7) | 241 (8.4) | 131 (4.2) | 0 | 0.01 | NHW>H&AI |
| - Self-pay | 261 (4.0) | 31 (1.1) | 231 (7.4) | 0 | <0.001 | H>NHW&AI |
| Contraceptive Choice4 | ||||||
| IUD | 2421 (37.1) | 105 (36.6) | 125 (40.1) | 12 (22.6) | 0.48 | |
| Implant | 15 (2.3) | 4 (1.4) | 9 (2.9) | 2 (3.8) | 0.27 | |
| OCPs | 177 (27.1) | 82 (28.6) | 83 (26.6) | 12 (22.6) | 0.68 | |
| Patch | 4 (0.61) | 0 | 3 (1.0) | 1 (1.9) | 0.10 | |
| Ring | 11 (1.69) | 4 (1.4) | 6 (2.2) | 1 (1.9) | 0.81 | |
| DMPA | 35 (5.4) | 4 (1.4) | 19 (6.1) | 12 (22.6) | < 0.001 | NHW<H<AI |
| Condoms | 63 (9.67) | 34 (11.8) | 25 (8.0) | 4 (7.5) | 0.13 | |
| Other3 | 52 (7.97 | 28 (9.8) | 18 (5.8) | 6 (11.3) | 0.10 | |
Continuous variables analyzed by one-way ANOVA and categorical variables analyzed by chi-square or Fisher's exact test.
Denominator includes missing values. Overall missing values less than 8%
N (%) reported
Other – includes diaphragm, withdrawal, and natural family planning
Choice of contraception before discharge from the hospital.
EAB – Elective abortion; SAB – Spontaneous abortion; IUD – Intrauterine device; OCP – Oral Contraceptive Pills; DMPA – Depomedroxyprogesterone acetate
The IUD was a common contraceptive selected by Hispanic and NHW women followed by OCPs and condoms. Among AI women, IUD, OCPs and DMPA were the most popular choices (Table 1).
Ethnicity did not influence postpartum choice of IUD/implant or pills/patch/ring (Table 2). Women under age 25 (OR 2.32, 95% CI 1.43 −2.86) and those who stated the index pregnancy was unplanned (OR 1.78, 95% CI 1.25 – 2.46) were more likely to choose an IUD or implant (Table 2).
Table 2.
Predictors of immediate postpartum choice of contraceptive method
| Contraceptive Methods | Unadjusted | Adjusted | ||
|---|---|---|---|---|
| OR (95% CI) | p value | OR (95% CI) | p value | |
| IUD/Implant | IUD/Implant | IUD/Implant | ||
| Ethnicity | ||||
| - NHW | Referent | 0.07 | Referent | 0.06 |
| - Hispanic | 1.27 (0.91 – 1.76) | 1.04 (0.73 – 1.47) | ||
| - American Indian | 0.62 (0.32 – 1.21) | 0.46 (0.22 – 0.92) | ||
| Age ≥ 25 years | 0.45 (0.33 – 0.63) | <0.001 | 0.49 (0.35 – 0.70) | <0.001 |
| BMI ≥ 25 | 0.95 (0.69 – 1.31) | 0.76 | ||
| Weight gain ≥ 15 kg | 1.32 (0.96 – 1.82) | 0.08 | ||
| ≥ 4 year college education | 0.52 (0.36 – 0.76) | <0.001 | ||
| Unplanned pregnancy | 2.05 (1.48 – 2.84) | <0.001 | 1.78 (1.25 – 2.46) | 0.001 |
| Late prenatal care | 1.15 (0.78 – 1.69) | 0.47 | ||
| ≥ 12 prenatal visits | 1.21 (0.88 – 1.67) | 0.25 | ||
| Breastfeeding immediately PP | 0.51 (0.24 – 1.1) | 0.09 | ||
| Postpartum visit | 1.62 (1.01 – 2.60) | 0.04 | ||
| Married/Cohabitating | 0.59 (0.41 – 0.84) | 0.003 | ||
| Insurance at time of delivery | ||||
| - Private | Referent | 0.02 | ||
| - Medicaid | 1.41 (0.98 – 2.02) | |||
| - Military | 2.56 (1.25 – 5.35) | |||
| - Self-pay | 0.62 (0.23 – 1.63) | |||
| Pills/Patch/Ring | Pills/Patch/Ring | Pills/Patch/Ring | ||
|---|---|---|---|---|
| Ethnicity | ||||
| - NHW | Referent | 0.95 | Referent | 0.81 |
| - Hispanic | 0.97 (0.68 – 1.39) | 0.92 (0.64 – 1.33) | ||
| - American Indian | 0.90 (0.46 – 1.76) | 0.79 (0.36 – 1.72) | ||
| Age ≥ 25 years | 1.25 (0.89 – 1.76) | 0.20 | ||
| BMI ≥ 25 | 1.01 (0.71 – 1.42) | 0.97 | ||
| Weight gain ≥ 15 kg | 0.88 (0.62 – 1.24) | 0.46 | ||
| ≥ 4 year college education | 1.36 (0.94 – 1.98) | 0.11 | ||
| Unplanned pregnancy | 0.86 (0.61-1.22) | 0.40 | ||
| Late prenatal care | 1.06 (0.70 -1.60) | 0.77 | ||
| ≥ 12 prenatal visits | 0.90 (0.63 – 1.27) | 0.54 | ||
| Breastfeeding immediately PP | 1.69 (0.67 – 4.24) | 0.26 | ||
| Postpartum visit | 0.66 (0.42 – 1.05) | 0.08 | ||
| Married/Cohabitating | 1.53 (1.03 – 2.28) | 0.04 | 1.50 (1.00 – 2.25) | 0.04 |
| Insurance at time of delivery | ||||
| - Private | Referent | 0.15 | ||
| - Medicaid | 0.90 (0.61 – 1.32) | |||
| - Military | 0.58 (0.25 – 1.35) | |||
| - Self-pay | 2.03 (0.86 – 4.8) | |||
| DMPA | DMPA | DMPA | ||
|---|---|---|---|---|
| Ethnicity | ||||
| - NHW | Referent | <0.001 | Referent | <0.001 |
| - Hispanic | 4.59 (1.54 – 13.68) | 3.44 (1.12 – 10.58) | ||
| - American Indian | 22.63 (6.92 – 74.02) | 15.28 (4.49 – 52.04) | ||
| Age ≥ 25 years | 0.62 (0.30-1.26) | 0.19 | ||
| BMI ≥ 25 | 0.79 (0.39 – 1.60) | 0.51 | ||
| Weight gain ≥ 15 kg | 0.94 (0.46-1.90) | 0.86 | ||
| ≥ 4 year college education | 0.14 (0.03 – 0.58) | 0.006 | 0.22 (0.05 – 0.99) | 0.05 |
| Unplanned pregnancy | 0.49 (0.24-1.02) | 0.06 | 0.43 (0.20 – 0.92) | 0.03 |
| Late prenatal care | 2.23 (1.06 – 4.73) | 0.04 | ||
| ≥ 12 prenatal visits | 0.30 (0.14 – 0.68) | 0.004 | ||
| Breastfeeding immediately PP | 0.51 (0.15 – 1.79) | 0.29 | ||
| Postpartum visit | 0.31 (0.15 – 0.64) | 0.001 | ||
| Married/Cohabitating | 0.45 (0.21 – 0.95) | 0.04 | ||
| Insurance at time of delivery | 0.01 | |||
| - Private | Referent | |||
| - Medicaid | 15.36 (2.08 – 113.69) | |||
| - Military | 5.09 (0.31-83.24) | |||
| - Self-pay | 35.60 (3.79 – 334.18) | |||
Cell format – OR (95% CI); NHW – Non Hispanic white; IUD – Intrauterine device; DMPA – depomedroxyprogesterone acetate; BMI – body mass index; PP – postpartum. Late prenatal care defined as initiation in the second trimester or later.
Best model by stepwise logistic regression is reported. IUD/Implant model – candidate factors included ethnicity, age, weight gain, education, pregnancy intention, breastfeeding, relationship status, postpartum visit and insurance at time of delivery. Pills/Patch/Ring model – candidate factors included ethnicity, age, education, postpartum visit, relationship status, and insurance at time of delivery. DMPA model – candidate factors included ethnicity, age, education, pregnancy intention, and initiation of prenatal care, number of prenatal visits, postpartum visit, relationship status and insurance at time of delivery.
Hispanic (OR 3.44, 95% CI 1.12 – 10.58) and AI (OR 15.28, 95% CI 4.49 – 52.04) women were more likely to choose DMPA compared to NHW women after controlling for other predictors including age, education, pregnancy intention, initiation of prenatal care, number of prenatal visits, postpartum visit, relationship status and insurance at time of delivery (Table 2). Women who had completed 4 years of college (OR 0.22, 95% CI 0.05 – 0.99) or who reported the index pregnancy as unplanned (OR 0.43, 95% CI 0.20 – 0.92) were less likely to choose DMPA. Ethnicity and age interactions were not significant (all p > 0.05).
DISCUSSION
Ethnicity did not influence the majority of immediate postpartum contraceptive choices. The IUD was chosen by 37% women overall and 40% of Hispanic women. AI women were less likely to use the IUD/Implant compared to the other ethnicities, however the differences did not reach statistical significance when adjusted for baseline differences between groups. Nationwide IUDs are used by only 7.7% of reproductive age women with higher rates (13.8 %) in Hispanic women (8). An older retrospective study of UNM postpartum women reported that 11.9% chose an IUD for contraception (9). We surmise a progressively IUD/Implant-friendly environment at UNM over the past few years has translated into the higher uptake of these methods.
AI and Hispanic women were more likely than NHW women to use DMPA. Compared to NHW women, Hispanic women reported the index pregnancy as unplanned and both Hispanic and AI women were less likely to complete college; factors that also positively influenced uptake of DMPA. While we found an association between the use of DMPA and ethnicity, the numbers are too small to draw definitive conclusions.
Our study has some limitations. New Mexico is a minority/majority state and the ethnic composition of this study reflects the population of New Mexico and may not be generalizable to other states (10). UNM maternity care services actively promote IUD and implant uptake, which may not be reflective of practices in other parts of the US. Strengths include blinding of research team members extracting data to ethnicity. Ninety seven percent of records documented a contraceptive choice or refusal indicating consistent counseling.
Race and ethnicity are potential factors affecting contraceptive use. An improved understanding of factors guiding a woman's choice could advance counseling and impact the uptake and continuation of effective contraception. In a setting where LARCs are promoted as first line choice for postpartum women, uptake is high regardless of ethnicity.
Acknowledgments
We would like to thank Dr. Clifford Qualls of the University of New Mexico Clinical and Translational Science Center, #1UL1RR031977-01 for help with the statistical analysis and Anne Fullilove for assistance with all aspects of study conduct and implementation.
Sources of financial support:
This project was supported in part by New Mexico Medical Trust funds from University of New Mexico School of Medicine Research Allocation Committee grant (UNM SOM RAC) (C-2349-R). The content is solely the responsibility of the author(s) and does not necessarily represent the official views of the UNM SOM RAC.
This project was supported in part by the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health through Grant Number UL1 TR000041. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Footnotes
Disclosure statement of any potential conflict of interest: The authors report no conflict of interest.
Paper presentation information: This study was presented as a poster at the 2012 North American Forum on Family Planning, Denver, CO, October 28-29, 2012.
For reprint requests: None available
IMPLICATIONS
Ethnicity may affect contraception choice. Contraceptive choice did not vary between ethnic groups for most methods. We found that compared with non-Hispanic white women, postpartum primiparous Hispanic and American Indian women chose depot medroxyprogesterone acetate more often.
Contributor Information
Rameet H. Singh, University of New Mexico School of Medicine Department of Obstetrics and Gynecology, Albuquerque, New Mexico.
Rebecca G. Rogers, University of New Mexico School of Medicine Department of Obstetrics and Gynecology, Albuquerque, New Mexico.
Lawrence Leeman, University of New Mexico School of Medicine Department of Family and Community Medicine, Albuquerque, New Mexico.
Noelle Borders, University of New Mexico School of Medicine Department of Obstetrics and Gynecology, Albuquerque, New Mexico.
Jessica Highfill, University of New Mexico School of Medicine Department of Obstetrics and Gynecology, Albuquerque, New Mexico.
Eve Espey, University of New Mexico School of Medicine Department of Obstetrics and Gynecology, Albuquerque, New Mexico.
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