Abstract
BACKGROUND
Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear.
OBJECTIVE
This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes.
STUDY DESIGN
This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016–2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery.
RESULTS
Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated.
CONCLUSION
Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.
Key words: disparity, maternal health, postpartum contraception, short interpregnancy interval, sterilization
AJOG Global Reports at a Glance.
Why was this study conducted?
Approximately half of patients requesting postpartum permanent contraception do not undergo the desired procedure. Nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery. However, the long-term reproductive and maternal health outcomes of nonfulfillment of desired postpartum permanent contraception are presently unknown.
Key findings
Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). Twenty-two (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There was no difference between the 2 groups in ever attending outpatient, preventive, or emergency room visits, nor in most nonreproductive health outcomes investigated in the 4 years following delivery.
What does this add to what is known?
Although subsequent pregnancy rates within 1 year of delivery have been reported, we present the impact on subsequent pregnancy for 4 years following delivery, demonstrating that some patients who did not have their permanent contraception procedure had 3 subsequent pregnancies. Importantly, this study more broadly conceptualizes health outcomes, including vital signs, healthcare utilization, nonreproductive morbidity, reproductive morbidity, and diagnosis of sexually transmitted infection.
Introduction
Recently, there has been a call to reduce maternal morbidity and mortality by increasing focus on improvement of maternal health outside of pregnancy and across the lifespan.1 There are increased risks of maternal and neonatal morbidity and mortality (largely from preeclampsia, uterine rupture, preterm birth, and low birthweight) associated with short interpregnancy intervals (<18 months between pregnancies). Thus, there has been considerable focus on increased access to and provision of postpartum contraception as an intervention with proven efficacy in reducing the incidence of short interpregnancy intervals.2, 3, 4, 5 Provision of highly effective methods of contraception, such as permanent contraception and long-acting reversible contraception (LARC), reduces the incidence of short interpregnancy intervals given their high efficacy rates and low reliance on patient adherence.6, 7, 8
However, numerous barriers to postpartum permanent contraception exist at the patient, provider, hospital, and policy levels.9, 10, 11, 12, 13, 14, 15, 16 Up to 50% of patients requesting postpartum permanent contraception do not undergo the desired procedure, and subsequent pregnancy rates between 25% and 50% within 1 year of delivery have been reported.17, 18, 19 Compared with patients who did not request postpartum permanent contraception, patients with unfulfilled permanent contraception requests experience double the rate of pregnancy within 1 year of delivery.18
Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear.17, 18, 19 Therefore, we sought to examine the association of nonfulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal and pregnancy health outcomes. We hypothesized that nonfulfillment of a patient's desired postpartum permanent contraception would be associated with increased risk of short interpregnancy intervals and reproductive and nonreproductive morbidity in the 4 years following delivery.
Materials and Methods
This was a retrospective cohort study of patients who desired female permanent contraception as their postpartum contraceptive plan and delivered at ≥20 weeks of gestation from January 1, 2012 through December 31, 2014 at our urban, tertiary-care teaching hospital—MetroHealth Medical Center, Case Western Reserve University. Full methodological details to identify the study cohort have been previously published.19 For this analysis, one trained researcher (A.F.) newly abstracted records, to extend the study time frame from 1 year per the initial methodology to 4 years after delivery (2016–2018).
Briefly, female permanent contraception was noted as a patient's postpartum contraceptive plan if it was thus documented in the hospital discharge summary or, if not included there, in the last inpatient postpartum progress note. All study participants had a contraceptive plan documented in 1 of these 2 places. For patients for whom permanent contraception was the intended contraceptive plan in multiple pregnancies in the study time frame, only the first pregnancy was included. We excluded patients who suffered peripartum mortality and any patients who had received permanent contraception before the study (but used in vitro fertilization for the delivery within the study time frame) because their permanent contraception requests did not need to be fulfilled. Of the initial cohort of 8654 patients who delivered from 2012 to 2014 inclusive, 1331 (15.4%) desired permanent contraception and thus met the criteria for inclusion in this study.
We reviewed both the outpatient and inpatient medical records, which are linked in a single electronic medical record in our healthcare system. Clinical and demographic characteristics recorded previously included maternal age, parity, gestational age, delivery type, number of prenatal visits, route of delivery, race and ethnicity, marital status, and education. Insurance status was directly obtained by matching patient charts to billing records. Whether a permanent contraception surgery (abdominal, laparoscopic, or hysteroscopic) was achieved within 90 days of delivery was recorded in this initial abstraction process. In addition, if permanent contraception was not achieved within 90 days of delivery, the contraceptive plan used within that time frame was also recorded. The 90-day threshold was used because of our hospital's policy at that time of scheduling outpatient postpartum visits at 6 weeks postpartum. This extended time frame allows for service recovery of patients who missed their initial postpartum visit and patients whose permanent contraception surgery was not scheduled until after the postpartum visit.
For the 4 years following delivery, we reviewed each participant's electronic medical record for mortality, subsequent intrauterine and ectopic pregnancies, last recorded vital signs (blood pressure, weight, body mass index [BMI]), healthcare utilization (outpatient problem-based visits, outpatient preventive care visits, emergency room visits), nonreproductive morbidity (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), reproductive morbidity (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise), and diagnosis of sexually transmitted infection. Inpatient provision of postpartum LARC was not available at our hospital (or any other hospital in Cuyahoga County) during the delivery period studied.
We calculated differences in demographic and clinical variables across permanent contraception fulfillment categories using t-tests, chi-square, Mann–Whitney, and Fisher exact tests, as appropriate, for parametric vs nonparametric outcomes. We also calculated time to permanent contraception fulfillment and provision of alternative contraception, and differences in number and time to diagnosis for subsequent intrauterine and ectopic pregnancies. Finally, we performed descriptive statistics of medical comorbidities in the index and subsequent pregnancies across permanent contraception fulfillment groups.
We performed statistical analyses using R, version 3.4.0 (R Core Team, Vienna, Austria).20 All tests were 2-tailed and an α of 0.05 was used to define statistical significance. Complete data were available for 1228 (92.2%) records. The Fleiss kappa statistic for all 4 initial abstracters was 0.91 for female permanent contraception as the documented contraceptive plan and 0.91 for concordance on whether female permanent contraception had been achieved. This study was approved by the Institutional Review Board of MetroHealth Medical Center.
Results
Of the 1331 patients desiring female permanent contraception, 588 (44.2%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment were more likely to be older, married, and college-educated, and attended more outpatient prenatal visits. There were also differences in route of delivery and insurance status between the 2 groups (Table 1).
Table 1.
Demographic and clinical characteristics of patients who desired postpartum permanent contraception at MetroHealth Medical Center
| Characteristics | Received | Did not receive | P value |
|---|---|---|---|
| Number of participants | 588 | 743 | |
| Median maternal age at delivery (y) | 31 (27–35) | 29 (26–34) | <.001 |
| Parity at admission | .45 | ||
| 0 | 10 (1.7%) | 19 (2.6%) | |
| 1 | 132 (22.4%) | 154 (20.7%) | |
| ≥2 | 446 (75.9%) | 570 (76.7%) | |
| Median gestational age at delivery (wk) | 39 (37–39) | 38 (37–39) | .85 |
| Insurance | .004 | ||
| Medicaid | 430 (73.1%) | 600 (80.8%) | |
| Private | 86 (14.6%) | 69 (9.3%) | |
| Medicare | 49 (8.3%) | 56 (7.5%) | |
| None | 23 (3.9%) | 18 (2.4%) | |
| Prenatal visits | 10 (7–12) | 8 (5–11) | <.001 |
| Missing | 3 (0.5%) | 17 (2.3%) | |
| Delivery type | <.001 | ||
| Spontaneous vaginal | 155 (26.4%) | 587 (79.0%) | |
| Operative vaginal | 8 (1.4%) | 20 (2.7%) | |
| Cesarean delivery | 425 (72.3%) | 136 (18.3%) | |
| Race | .07 | ||
| Black/African American | 268 (45.6%) | 397 (53.4%) | |
| White | 191 (32.5%) | 211 (28.4%) | |
| Hispanic | 106 (18.0%) | 107 (14.4%) | |
| Asian | 6 (1.0%) | 7 (0.9%) | |
| Other | 17 (2.9%) | 21 (2.8%) | |
| Married | 171 (29.8%) | 127 (17.6%) | <.001 |
| Missing | 14 (2.4%) | 20 (2.7%) | |
| College education | 201 (35.9%) | 207 (29.0%) | .02 |
| Missing | 28 (4.8%) | 28 (3.8%) |
Presented as number (percentage) or median (interquartile range).
Ford. Postpartum permanent contraception and maternal health. Am J Obstet Gynecol Glob Rep 2022.
The Figure depicts study inclusion information and data regarding the number and timing of subsequent pregnancies (intrauterine and ectopic). Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). There were no differences in rates of subsequent ectopic pregnancies (odds ratio, 0.50; 95% confidence interval, 0.08–3.09) between the groups within 4 years after the index delivery, although the absolute numbers were low, thereby limiting analysis. Three patients who had received permanent contraception (0.5%) became pregnant in the 4 years following delivery, including 1 intrauterine and 2 ectopic pregnancies, whereas 192 of 743 (25.8%) who did not receive permanent contraception had subsequent pregnancies. Among women who did not receive permanent contraception surgery within 90 days of delivery, 174 (23.4%) had a subsequent short interpregnancy interval. Of the 192 women with a subsequent pregnancy within 4 years of delivery after permanent contraception nonfulfillment, 174 (90.6%) had short interpregnancy intervals. Forty-three (22.4%) of these 192 women had a second subsequent pregnancy, of whom 40 (93.0%) had short interpregnancy intervals.
Figure.
Study inclusion information and data regarding subsequent pregnancies
Study flow diagram and reproductive health outcomes in the 4 years following delivery for patients who received desired permanent contraception surgery postpartum compared with those who did not
Ford. Postpartum permanent contraception and maternal health. Am J Obstet Gynecol Glob Rep 2022.
Of the 588 patients who received permanent contraception, 407 (69.2%) received it on the day of delivery, 47 (8.0%) during the delivery admission, 9 (1.5%) during the first 6 weeks after delivery, and 125 (21.2%) within 90 days postpartum. Of the 743 who did not undergo their desired permanent contraception surgery by 90 days postpartum, only 105 (14.1%) received an alternative prescribed contraceptive method during that time frame. This included both long-acting reversible contraceptive (32 patients; 4.3%) and short-acting reversible prescribed methods (73 patients; 9.8%). Furthermore, only 8 of these 743 patients obtained permanent contraception within the 4-year study time frame.
Maternal nonreproductive health outcomes are shown in Table 2. There was no difference in ever having an outpatient, preventive, or emergency room (ER) visit within 4 years following delivery. However, patients who had received permanent contraception had fewer outpatient (P=.04) and preventive care visits (P<.001) in the 4-year time frame. There was no difference in the number of ER visits (P=.64), blood pressure at delivery, blood pressure 4 years after delivery, or change in blood pressure between the 2 groups. Those who received permanent contraception within 90 days of delivery were more likely to have a higher BMI (42.8 in permanent contraception fulfilled vs 41.3 in not fulfilled group; P=.02), but this difference was no longer present 4 years after delivery (39.2 vs 38.6; P=.34). Those who had received permanent contraception were more likely to have a higher net loss in BMI in the 4-year time frame (delta −3.6 vs −2.6; P=.005). Patients who received permanent contraception were more likely to develop diabetes mellitus in the following 4 years (22 [3.7%] vs 9 [1.2%]; P=.009).
Table 2.
Maternal nonreproductive and reproductive health outcomes at delivery and at 4 years after index delivery by postpartum permanent contraception fulfillment status
| Health outcomes | Received | Did not receive | P value |
|---|---|---|---|
| Number of participants | 588 | 743 | |
| Healthcare utilization | |||
| Outpatient visits—ever | 545 (92.7) | 687 (92.5) | .20 |
| Outpatient visits—number | 9.81 (10.52) | 11.04 (11.22) | .004 |
| Preventive visits—ever | 482 (82.0) | 618 (83.2) | .15 |
| Preventive visits—number | 3.28 (4.09) | 5.03 (5.73) | <.001 |
| ER visits—ever | 423 (71.9) | 544 (73.2) | .16 |
| ER visits—number | 3.95 (6.03) | 3.92 (4.94) | .93 |
| Nonreproductive health outcomes | |||
| Blood pressure | |||
| SBP at delivery (mm Hg) | 122.0 (15.41) | 120.6 (14.68) | .09 |
| SBP at 4 y (mm Hg) | 123.0 (17.28) | 122.9 (17.35) | .86 |
| Delta SBP | 0.9 (18.43) | 2.1 (19.02) | .29 |
| DBP at delivery (mm Hg) | 71.4 (10.88) | 70.6 (10.91) | .18 |
| DBP at 4 y (mm Hg) | 74.2 (14.12) | 73.4 (12.62) | .26 |
| Delta DBP | 2.7 (15.21) | 2.8 (14.04) | .88 |
| Weight | |||
| Weight at delivery (lbs) | 208.7 (55.16) | 203.0 (51.50) | .05 |
| Weight at 4 y (lbs) | 192.0 (60.31) | 191.8 (56.92) | .95 |
| Delta weight | −17.6 (25.78) | −12.0 (25.37) | <.001 |
| BMI | |||
| BMI at delivery (kg/m2) | 42.8 (10.45) | 41.3 (9.70) | .02 |
| BMI at 4 y (kg/m2) | 39.2 (11.71) | 38.6 (10.94) | .38 |
| Delta BMI | −3.6 (5.33) | −2.6 (5.17) | .005 |
| Hypertension at 4 y | .89 | ||
| Preexisting | 65 (11.1) | 74 (10.0) | |
| New diagnosis | 23 (3.9) | 26 (3.5) | |
| Diabetes mellitus at 4 y | .009 | ||
| Preexisting | 29 (4.9) | 31 (4.2) | |
| New diagnosis | 22 (3.7) | 9 (1.2) | |
| Depression at 4 y | .36 | ||
| Preexisting | 102 (17.3) | 132 (17.8) | |
| New diagnosis | 19 (3.2) | 35 (4.7) | |
| Anxiety at 4 y | .73 | ||
| Preexisting | 49 (8.3) | 56 (7.5) | |
| New diagnosis | 19 (3.2) | 21 (2.8) | |
| Asthma at 4 y | .31 | ||
| Preexisting | 93 (15.8) | 111 (14.9) | |
| New diagnosis | 11 (1.9) | 16 (2.2) | |
| Anemia at 4 y | .10 | ||
| Preexisting | 44 (7.5) | 80 (10.8) | |
| New diagnosis | 24 (4.1) | 26 (3.5) | |
| Sexually transmitted disease at 4 y | 55 (9.4) | 98 (13.2) | .07 |
| Mortality | 4 (0.7) | 1 (0.1) | .20 |
| Reproductive health outcomes | |||
| Gestational diabetes mellitus | 13 (1.7) | — | |
| Preeclampsia | 13 (1.7) | — | |
| Gestational hypertension | 3 (0.4) | — | |
| Postpartum hemorrhage | 1 (0.1) | — | |
| Subsequent preterm birth | 26 (3.5) | — | |
| Low birthweight | 1 (0.1) | — | |
| Intrauterine fetal demise | 2 (0.3) | — | |
Presented as number (percentage) or mean (standard deviation).
BMI, body mass index; DBP, diastolic blood pressure; ER, emergency room; SBP, systolic blood pressure.
Ford. Postpartum permanent contraception and maternal health. Am J Obstet Gynecol Glob Rep 2022.
Reproductive health outcomes in the 4 years following the index delivery were calculated and are also shown in Table 2. Of the patients who did not achieve permanent contraception fulfillment, 13 (1.7%) were diagnosed with gestational diabetes mellitus, and 13 (1.7%) developed preeclampsia. In addition, 26 (3.5%) had a subsequent preterm birth, representing a preterm birth rate of 14.6% (26 preterm births of 178 continued pregnancies).
Comment
Principal findings
In our single-institution retrospective cohort study, patients who did not receive their desired postpartum permanent contraception surgery within 90 days postpartum were unlikely to undergo permanent contraception at a later point or receive alternative contraception, and were more likely to have subsequent pregnancies within 4 years of index delivery compared with patients who did receive their desired postpartum permanent contraception. Most of these subsequent pregnancies occurred after short interpregnancy intervals, within 18 months of the previous pregnancy. The preterm birth rate of 14.6% in patients who did not receive a desired postpartum permanent contraception surgery is higher than the statewide 10.3% preterm birth rate.21
Results in the context of what is known
This study extends our current understanding of the implications of nonfulfillment of a desired postpartum permanent contraception procedure. Although subsequent pregnancy rates within 1 year of delivery have been reported, we present the impact on subsequent pregnancy for 4 years following delivery.16, 17, 18 Of note, our study population was of an age similar to that observed in one study (Thurman and Janecek) and in national trends of permanent contraception provision, but slightly older than that presented in another study on pregnancy after nonfulfillment of permanent contraception (Zite et al).16,18,22 Importantly, this study conceptualized health outcomes more broadly, including vital signs, healthcare utilization, nonreproductive morbidity, reproductive morbidity, and diagnosis of sexually transmitted infection.
Clinical implications
In our study, only 14% of patients who did not receive their desired postpartum permanent contraception surgery received an alternative method of contraception within 90 days postpartum, likely as a combination of not desiring an alternative method and structural barriers to returning to the outpatient postpartum visit. Thus, we believe it is important to counsel patients regarding the multiple known barriers to postpartum permanent contraception, inform them that approximately half of patients desiring permanent contraception are unable to receive the surgery within 90 days postpartum, and explain the likelihood that unfulfilled requests after 90 days will not be fulfilled in the months to follow.9,16,19 Such transparency is crucial to patient empowerment and informed consent. Furthermore, although removing barriers as possible and advocating for each patient to receive her desired method of contraception, we believe it is prudent to discuss contingency contraceptive plans with patients desiring postpartum permanent contraception in case it is not able to be provided during the delivery admission. Although it is unknown whether subsequent pregnancies in our study were desired, the fact that most occurred after short interpregnancy intervals, and the higher rate of preterm birth relative to the state average are important clinically for individual patient counseling and for public health. The low rate of provision of permanent contraception in future pregnancies also highlights that the clinical, structural, and policy barriers that likely contributed to nonfulfillment in the index pregnancy likely remain present in subsequent pregnancies.
Furthermore, there were clinical and demographic differences between patients receiving and not receiving their desired postpartum permanent contraception surgery. The policy barriers to postpartum permanent contraception related to insurance status have been well-described given the United States Medicaid sterilization policy.6,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 The association of cesarean delivery with completion of permanent contraception requests is likely because of the logistical barriers to postpartum permanent contraception after vaginal delivery. However, the association of permanent contraception receipt with age, marital status, and education is less clear. It has been previously demonstrated that implicit bias on the part of obstetrician-gynecologists may affect permanent contraception counseling specifically and contraceptive counseling more generally.11, 12, 13,23, 24, 25 Although this patient population may also have fewer barriers to receipt of an interval postpartum permanent contraception, as evidenced by the increased number of prenatal visits attended, the role of differential clinical practices because of bias needs to be further evaluated.
Research implications
Given the single-center nature of this study, we recommend analyzing the longer-term impact of nonfulfillment of desired permanent contraception postpartum more broadly. Furthermore, because our study was conducted when postplacental LARC was not available on our labor and delivery unit because of limitations in coverage by many health insurances in the United States during the study time frame, the impact of increased LARC availability on outcomes also warrants further study. Although the relationship between provision of permanent contraception and subsequent pregnancy outcomes is evident in this study, the relationship between nonfulfillment of permanent contraception and nonreproductive health outcomes is less clear. Given the momentum to recognize the importance of pregnancy as a window to future chronic health issues and the policy momentum to increase the length of insurance coverage postpartum, further study into this relationship is warranted.26 Because interventions to improve postpartum permanent contraception procedure fulfillment rates have been demonstrated, the impact of these measures on maternal health outcomes should also be investigated.27
Strengths and limitations
Strengths of this study include the comprehensive nature of our data set and the analysis of the impact of permanent contraception in the longer term and including more comprehensive health outcomes compared with previous studies. As a retrospective chart review, our study is limited by potential loss to follow-up. It is unclear whether patients who were not followed up did not access care at all or accessed care elsewhere. However, this potentially disproportionately affects patients with Medicaid because of the need for transferring signed Title XIX Sterilization Consent Forms to obtain permanent contraception in a timely fashion. Similarly, our data may underrepresent subsequent pregnancies for multiple reasons, including patients who choose to seek care at other institutions for subsequent pregnancies or to terminate subsequent pregnancies, given that our institution does not provide pregnancy termination services. Because this was a single-center study, permanent contraception practices and barriers related to our hospital's culture, policies, and procedures may limit generalizability. Finally, given our study methodology, we were not able to study effect, but rather association. We urge further and broader work to better understand the effect of nonfulfillment of permanent contraception on reproductive and nonreproductive health outcomes, including the comparison with the broader postpartum population that retains pregnancy potential.
Conclusion
Nonfulfillment of desired postpartum permanent contraception is associated with important maternal and child health ramifications. These include: the likelihood of female permanent contraception not being provided after the initial postpartum period; high rate of subsequent pregnancy despite previously articulated family planning goals; high rate of short interpregnancy intervals; and subsequent pregnancy comorbidity, particularly preterm birth. Given the barriers to permanent contraception receipt, alternative plans for contraception should be discussed in the case that female permanent contraception is not provided. Removing barriers to desired postpartum permanent contraception is important in terms of health outcomes for individual patients and public health.
Footnotes
The authors report no conflict of interest.
K.S.A. is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development branch of the National Institutes of Health (NIH) (1R01HD098127). She was previously funded by the Clinical and Translational Science Collaborative of Cleveland (KL2TR0002547), from the National Center for Advancing Translational Sciences component of the NIH and the NIH Roadmap for Medical Research, which was integral to the creation of the initial cohort. This manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Patient consent was not required because no personal information or details were included.
Cite this article as: Ford A, Ascha M, Wilkinson B, et al. Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes. Am J Obstet Gynecol Glob Rep 2022;XX:x.ex–x.ex.
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