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Abstract

Background:

The first wave of the COVID-19 pandemic was associated with restricted access to reproductive care including delayed abortion and female sterilization procedures, in addition to altered maternity care experiences. Given high rates of unintended and short-interval pregnancies in the United States in general and negative obstetric outcomes specifically associated with COVID-19, access to all effective pregnancy prevention methods during the pandemic was crucial.

Objectives:

To investigate changes in contraception utilization rates prior to delivery discharge, at outpatient postpartum visits, and at 10 weeks’ postpartum, at the largest healthcare system in Central Massachusetts, during the first wave of the COVID-19 pandemic (15 March to 15 May 2020), compared to the same period in 2019.

Design:

Retrospective cohort review.

Methods:

Compared perinatal individuals (n = 495) who received prenatal care and delivered at UMass Memorial Medical Center from mid-March to mid-May in both 2019 (non-pandemic) and 2020 (COVID-19 pandemic). Receipt of contraception prior to delivery discharge and at outpatient postpartum visit was estimated and compared between the two time periods using the Chi-square test for categorical variables (or Fisher’s exact test when cell counts were < 5) and Student’s t-test for continuous variables. Multivariable logistic regression was performed to adjust for confounders.

Results:

The proportion of individuals who used long-acting reversible contraception before delivery discharge was 4% in 2019 and 13% in 2020 (p = 0.01). Modes of outpatient postpartum visit contraception did not vary from 2019 to 2020, (p = 0.06). Overall, there were no differences in contraception utilization rates at 10 weeks’ postpartum from 2019 to 2020, (p = 0.50).

Conclusion:

Compared to a year prior, immediate postpartum long-acting reversible contraception use increased during the first wave of the COVID-19 pandemic, while overall contraception use at 10 weeks’ postpartum remained unchanged. The evaluation of contraceptive use during the most restrictive time of COVID-19 pandemic can help identify opportunities to increase access to effective contraception, such as the immediate postpartum period prior to hospital discharge.

Keywords

contraception COVID-19 long-acting reversible contraception

Introduction

The initial response to the coronavirus disease 2019 (COVID-19) pandemic affected pregnancy planning and maternity care including prenatal, postpartum, and contraceptive access.¹ A national survey (April to May 2020) found that 34% of respondents wanted to delay pregnancy or have fewer children because of the pandemic, and half of this group reported increased intention to use contraception at every sexual encounter.² Notably, 23% of respondents reported planning to get long-acting reversible contraception (LARC) due to the pandemic, yet 33% of those wanting LARC had trouble accessing their birth control or had to delay or cancel a reproductive health appointment.² Another survey demonstrated that Black, Indigenous, and Women of Color, along with those who experienced job or income loss and food insecurity were significantly more likely to report that they would use a different contraceptive method if it was not for COVID-19, indicating an unmet contraceptive need.³ The racial and income disparities of COVID-19 hospitalizations, mortality, and contraceptive access are well documented, and the pandemic further compounded pre-existing social inequities.^4,5

High levels of unintended pregnancies and short interpregnancy intervals are related to unmet contraceptive needs. In 2011, the unplanned pregnancy rate in the United States was 45%.⁶ Short interpregnancy interval (< 18 months) is associated with increased risks of adverse outcomes, including preterm delivery, small-for-gestational-age birth, and infant mortality, which can be reduced by access to effective contraception.⁷ Immediate postpartum LARC is safe and effective (99%) at preventing unwanted pregnancies and short interpregnancy interval.⁸

In the early stage of the pandemic, hospitals and clinics limited access to non-urgent in-person outpatient visits, delayed elective procedures including abortions and female sterilization, and imposed restrictions during labor and delivery.⁹ Significant care delays occurred and were multifactorial including public fear of viral exposure when accessing medical facilities, capacity issues, and others.¹⁰ Telehealth services rapidly expanded to increase access to clinical care. Although telehealth can be convenient for patients, contraceptive methods that can be prescribed via telehealth are limited. Depot medroxyprogesterone acetate (DMPA), LARC placement, and female sterilization require in-person care.

The objective of this study was to investigate changes in contraception utilization rates prior to delivery discharge, at outpatient postpartum visits (OPPVs), and overall use by 10 weeks’ postpartum at the largest healthcare system in Central Massachusetts, during the first wave of the COVID-19 pandemic (15 March to 15 May 2020), compared to the same period in 2019. We hypothesized an increase in immediate postpartum LARC use due to convenience of minimizing future in-person visits and decreased use at the OPPV due to fewer in-person visits during wave 1 of the pandemic as compared to the same period in 2019.

Methods

Study design

This retrospective cohort study involved review of medical records after approval by the University of Massachusetts Chan Medical School’s Institutional Review Board’s Human Subjects Committee. The medical records of 495 individuals who received prenatal care and delivered at UMass Memorial Medical Center (UMMMC) from 15 March to 15 May 2019 and 15 March to 15 May 2020 were reviewed. The 2020 dates corresponded with the height of wave 1 of the COVID-19 pandemic in the United States and during which there was a state of emergency and the greatest restrictions regarding in-person healthcare delivery at our institution were in effect. Our team agreed that collecting data from a sample of approximately 500 consecutive patients that met predefined criteria would minimize bias given the unprecedented time and pandemic-forced social experiment. Formal sample size calculation was not performed and 4 months corresponded with the time of greatest COVID-related restrictions on non-urgent in-person care.

Data were obtained from the EPIC electronic medical record of UMMMC by individual abstraction and manually input into REDCap, a secure web platform for managing data (Vanderbilt University. 2021. REDCap 11.0.1).¹¹ STROBE, a reporting guideline for observational studies was used.¹² Patients were identified through EPIC by searching all records for persons who delivered at UMMMC between the designated dates and were included if the following criteria were met: (1) had an inpatient delivery by a UMass faculty attending and (2) received prenatal care at UMMMC (see Figure 1). Exclusion criteria were lack of immediate postpartum contraception documentation in the delivery hospitalization or missing information to determine eligibility. Demographic characteristics were collected.

Figure 1.

Identification of a cohort of individuals who delivered a live-born between 15 March and 15 May 2019 and the same period in 2020 by a UMMMC obstetrics and gynecology faculty, with routine prenatal care at UMMMC, and documentation of postpartum contraception use.

Environment

UMMMC is the largest safety net hospital in Central Massachusetts. The caregivers of UMMMC serve a large racially and ethnically diverse and low English proficiency population. All UMMMC obstetrics and gynecology faculty and resident physicians undergo standardized postpartum contraception counseling training. In response to the pandemic, a department-wide educational refresher was delivered in March 2020 to increase antenatal education on immediate postpartum contraception. The protocol included prenatal counseling and documentation of counseling and postpartum contraception preference; this was reviewed during the patient’s delivery admission. Physicians provided additional counseling to patients who were undecided with contraceptive choice from admission through discharge until preference was known. Non-English-speaking patients were counseled using video interpreter services. For those interested and without contraindications, immediate postpartum intrauterine devices (IUDs) were placed within 10 min of placental delivery. Those who desired IUDs after this period were offered pre-discharge hormonal implants or IUD placement at their OPPV, with other interval short-acting hormonal contraception provided. Private health insurance did not reimburse LARC before delivery discharge outside of the global pregnancy episode; thus, only patients with public insurance were offered immediate postpartum LARC. Privately insured patients who desired LARC were offered pre-discharge options, such as progestin only pills and DMPA, as interval contraception until their OPPV.

Dependent variables

The outcomes of interest were (1) prescription or use of contraception before discharge, (2) prescription or use of early postpartum contraception at OPPV, and (3) use of contraception by 10 weeks’ postpartum. Postpartum contraception was recorded from the delivery hospitalization record, OPPV documentation, and/or the medication list in the outpatient record. The immediate postpartum period was defined as the time from inpatient pregnancy delivery to delivery discharge. The early postpartum period was considered the time from delivery discharge to OPPV. Attendance at an OPPV included a telehealth or in-person visit occurring within 10 weeks’ from delivery discharge. All 495 patients were analyzed for contraception use at the time of 10 weeks’ postpartum, assessed by the last contraception documentation prior to 10 weeks’ postpartum. Those who did not attend an OPPV were analyzed at 10 weeks’ postpartum using their pre-discharge contraception method, given that none had additional contraception documentation.

Independent variables

The primary independent variable was time, comparing deliveries from 15 March to 15 May 2020 and the same period in 2019. Potential confounders included insurance type, delivery type, maternal age, illicit drug use, due to potential to influence contraception options and/or timing of implementation. Patient insurance types included private, public, or mixed, defined as both private and public insurance.

Operational definitions

LARC methods included IUDs and subdermal hormonal implants. Short-acting hormonal methods included oral contraceptive pills, vaginal ring, contraceptive patch, and DMPA injections. DMPA injections, LARC, and female sterilization were only administered in-person. No prescription contraception included lactational amenorrhea, fertility awareness planning, condoms, withdrawal, and no contraception; this category included individuals who received contraceptive counseling and declined prescription.

Statistical analysis

All patients were analyzed for contraceptive use at the immediate postpartum, early postpartum, and 10 weeks’ postpartum periods. The early postpartum analysis group included patients who attended an OPPV with potential for increased contraceptive effectiveness, including patients with immediate postpartum short-acting hormonal methods or no pre-discharge contraceptive prescription. Individuals with immediate postpartum short-acting hormonal methods were included in this group given that some patients elected use of interval or contraceptive methods, while their preferential choice was unavailable before hospital discharge. Receipt of tubal sterilization surgery in the early postpartum period was characterized under “female sterilization at OPPV.”

Patient characteristics and outcomes of interest were compared across time periods using the Chi-square test for categorical variables and Student’s t-test for continuous variables. Outcomes of interest were compared across insurance groups using the Chi-square test for categorical variables (or Fisher’s exact test when cell counts were < 5) and Student’s t-test for continuous variables. Unadjusted and adjusted logistic regression was used to compare outcomes by time point. To adjust for potential confounders, multivariable logistic regression was performed, and prevalence odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Covariates that were significantly different at the bivariate level (age, illicit drug use, insurance group, and cesarean delivery) were identified and included in the model. Logistic regression models with very small cell counts used a Firth bias correction to calculate odds ratios at 95% confidence intervals.¹³ Statistical significance was set at p < 0.05 for all comparisons. All analyses were performed using Stata MP 16.1 (StataCorp. 2020. Stata Statistical Software: Release 16. College Station, TX).

Result

Overall, patients in this sample were young, racially diverse with a large portion of Hispanic individuals, predominately publicly insured and delivered vaginally (see Table 1). All patients with mixed insurance had primary private insurance with secondary public insurance. Included patients (n = 495) were categorized into a flowchart based on contraception type and timing of receipt (see Figure 2).

Table 1.

Demographics of eligible individuals.

	2019(n = 251)	2020(n = 244)	p-value
	Mean (SD)	Mean (SD)	p-value
Age (year)	29.4 (6.0)	30.6 (5.4)	0.03
BMI (kg/m²)	29.0 (8.9)	29.4 (8.4)	0.654
	n (%)	n (%)
Race			0.35
Black	29 (14.1)	32 (13.5)
White	122 (59.5)	124 (52.3)
Asian	15 (7.3)	24 (10.1)
Other	39 (19.0)	57 (24.1)
Ethnic group			0.93
Hispanic or Latino ethnicity	76 (30.3)	73 (29.9)
Insurance type			0.96
Private	95 (37.8)	92 (37.7)
Public	141 (56.2)	136 (55.7)
Mixed	15 (6.0)	16 (6.6)
Illicit drug use during pregnancy	22 (8.8)	42 (17.3)	0.01
Delivery type			0.32
Vaginal	171 (68.1)	156 (63.9)
C-section	80 (31.9)	88 (36.1)

BMI: body mass index.

Bolded values indicate p < 0.05.

Figure 2.

Flowchart of postpartum contraceptive use from immediate postpartum to the 10-week postpartum visit.

Analysis by year

Table 2 displays contraceptive use at different postpartum periods by year and insurance status. Modes of immediate postpartum contraception vary significantly from 2019 to 2020 and were notable for increase in LARC. In COVID-19 wave 1 immediate postpartum period (2020), 7% of subjects received female sterilization, 13% had LARC placement, 32% received short-acting hormonal methods, and 48% did not receive contraceptive prescription, compared to 9%, 4%, 34%, and 53%, respectively, in the 2019 period (see Table 2). Modes of OPPV contraception did not vary from 2019 to 2020, (p = 0.06). There were no significant changes to attendance rates of OPPV between 2019 and 2020; however, telehealth visits changed from 0% in 2019 to 39% in 2020 (p < 0.01). Overall, there were no differences in contraceptive modes at 10 weeks’ postpartum from 2019 to 2020, (p = 0.50). None of the LARC devices were removed in the 10 weeks’ postpartum period.

Table 2.

Contraception type by year and by insurance status.

	2019	2020	p-value	Public	Private	Mixed	p-value
	n (%)	n (%)	p-value	n (%)	n (%)	n (%)	p-value
Immediate postpartum contraception mode	n = 251	n = 244	0.01	n = 277	n = 187	n = 31	< 0.01
No prescription contraception	132 (53)	117 (48)		112 (40)	123 (66)	14 (45)
Short-acting hormonal method	86 (34)	78 (32)		30 (11)	9 (5)	2 (7)
IUD or hormonal implant	10 (4)	31 (13)		41 (15)	0 (0)	0 (0)
Female sterilization	23 (9)	18 (7)		94 (34)	55 (29)	15 (48)
OPPV within 10 weeks	n = 251	n = 244	0.10	n = 277	n = 187	n = 31	< 0.01
No	67 (27)	50 (20)		88 (32)	22 (12)	7 (23)
Yes	184 (73)	194 (80)		189 (68)	165 (88)	24 (77)
OPPV type	n = 184	n = 194	< 0.01	n = 189	n = 165	n = 24	0.10
In-person	184 (100)	119 (61)		143 (76)	140 (85)	20 (83)
Telehealth	0 (0)	75 (39)		46 (24)	25 (15)	4 (17)
OPPV contraception mode^a	n = 163	n = 157	0.06	n = 140	n = 159	n = 22	0.13
No prescription contraception	81 (50)	98 (62)		68 (49)	96 (60)	15 (68)
Short-acting hormonal method	32 (20)	19 (12)		49 (35)	36 (23)	5 (23)
IUD or hormonal implant	49 (30)	40 (25)		23 (16)	26 (16)	2 (9)
Female sterilization	1 (1)	0 (0)		0 (0)	1 (1)	0 (0)
Overall contraception mode by 10 weeks’ postpartum^b	n = 251	n = 244	0.50	n = 277	n = 187	n = 31	< 0.01
No prescription contraception	79 (31)	73 (30)		63 (23)	77 (41)	12 (39)
Short-acting hormonal method	89 (35)	82 (34)		94 (34)	65 (35)	12 (39)
IUD or hormonal implant	59 (24)	71 (29)		90 (32)	35 (19)	5 (16)
Female sterilization	24 (10)	18 (7)		30 (11)	10 (5)	2 (6)

IUD: intrauterine device; OPPV: outpatient postpartum visit.

This cohort includes individuals who received immediate postpartum short-acting hormonal method or no immediate postpartum contraception and attended an outpatient postpartum visit.

This group includes n = 117 individuals who did not attend an OPPV and no subsequent documentation of contraception.

Bolded values indicate p < 0.05.

Table 3 shows unadjusted and adjusted (for maternal age, illicit drug use, insurance type, and delivery method) odds ratios comparing postpartum contraception outcomes in 2019 versus 2020. Patients delivering in early COVID-19 pandemic had over three times the odds of receiving LARC compared to short-acting hormonal methods for immediate postpartum contraception; this persisted after adjusted logistic regression (OR 3.1, 95% CI: 1.39–6.98). The early postpartum analysis group was 41% less likely to be prescribed any contraception at the OPPV during the pandemic, compared to 2019 (OR 0.59, 95% CI: 0.38–0.93). However, this finding did not persist after adjusted analyses (OR 0.63, CI: 0.40–1.00, p = 0.052). Sensitivity analysis of this model excluding telehealth visits showed there was no relationship between receiving contraception at OPPV and time point (OR 1.1, CI: 0.65–1.85). As such, OPPV telehealth patients were 85% less likely to receive any type of prescription contraception (data not shown).

Table 3.

Logistic regression results comparing postpartum contraception outcomes in 2020 versus 2019.

	Unadjusted		Adjusted^a
	OR	CI	OR	CI
Immediate postpartum
Received female sterilization immediately postpartum (n = 41; versus short-acting hormonal method, n = 164)
2019	Reference		Reference
2020	0.86	0.43–1.72	1.09	0.34–1.59
Received LARC immediately postpartum (n = 41; versus short-acting hormonal method, n = 164)
2019	Reference		Reference
2020	3.42	1.57–7.43	3.11	1.39–6.98
Received prescription contraception^b immediately postpartum (n = 246; versus no prescription contraception, n = 249)
2019	Reference		Reference
2020	1.20	0.85–1.71	1.16	0.80–1.69
Early postpartum
Received IUD or hormonal implant at outpatient postpartum visit^c (n = 89; versus short-acting hormonal method^c, n = 51)
2019	Reference		Reference
2020	1.35	0.67–2.72	1.54	0.72–3.30
Received prescription contraception^b at outpatient postpartum visit (n = 141; versus no prescription contraception, n = 179)
2019	Reference		Reference
2020	0.59	0.38–0.93	0.63	0.40–1.00
Sensitivity analysis – Received prescription contraception^b at in-person OPPV (n = 134; versus no prescription contraception, n = 131)
2019	Reference		Reference
2020	0.99	0.61–1.63	1.1	0.65–1.85
Overall at 10 weeks’ postpartum ^d
Received IUD or hormonal implant at 10 weeks’ postpartum (n = 130; versus short-acting hormonal method, n = 171)
2019	Reference		Reference
2020	1.31	0.83–2.06	1.29	0.79–2.08
Received prescription contraception^b at 10 weeks’ postpartum (n = 343; versus no prescription contraception, n = 152)
2019	Reference		Reference
2020	1.08	0.73–1.58	1.12	0.75–1.67

OR: odds ratio; CI: confidence interval; LARC: long-acting reversible contraception; IUD: intrauterine device; OPPV: outpatient postpartum visit.

Adjusted for maternal age, insurance type, illicit drug use, and delivery type.

Prescription contraception includes female sterilization, LARC, and short-acting hormonal method.

This cohort includes individuals who received immediate postpartum short-acting hormonal method or no immediate postpartum contraception and attended an outpatient postpartum visit.

This group includes n = 117 individuals who did not attend an OPPV and no subsequent documentation of contraception.

Bolded values indicate p < 0.05.

Since we assumed the contraception method at 10 weeks’ postpartum for patients who did not attend an OPPV, we performed two analyses to validate this method. We compared the distribution of overall contraception modes at 10 weeks’ postpartum of patients with OPPV attendance (n = 378) compared to all patients (n = 495) and found no difference p = 0.69 versus p = 0.50, respectively. Sensitivity analysis of this model found no interaction between time point and having an OPPV for overall receiving LARC (p = 0.83) or any contraception (p = 0.34).

Analysis by insurance type

Insurance type was also significantly associated with pre-discharge contraception use, overall contraception use, and OPPV non-attendance. Immediately postpartum, among patients with private insurance compared to public insurance, a higher percentage did not receive prescription birth control (66% versus 40%), fewer received female sterilization (5% versus 11%), and none received LARC (0% versus 15%), respectively (p < 0.01, see Table 2). Insurance status was also associated with OPPV attendance: 88% with private insurance versus 68% with public insurance attended their postpartum visit (p < 0.01, see Table 2). At 10 weeks’ postpartum, patients with private insurance versus public insurance were less likely to receive female sterilization (5% versus 11%), LARC (19% versus 32%), or any prescription contraception overall (p < 0.01, see Table 2).

Discussion

The COVID-19 pandemic changed prenatal and postpartum care delivery, including family planning and contraceptive counseling. The obstetrics and gynecology field experienced this through decreased in-person ambulatory visits and increased telehealth services, delayed surgeries and other care, and increased challenges to contraceptive access.^14,15 Thus, we hypothesized that highly effective immediate postpartum contraception that required infrequent clinical contact, such as LARC, would increase during the COVID-19 pandemic, which was supported by this study, although overall rates remained low.

Early in the pandemic, elective procedures, including bilateral tubal ligation, and in-person OPPVs were canceled at UMMMC for infection control precautions. Those who delivered by cesarean delivery during the pandemic could have bilateral tubal ligation concomitant with their delivery partially explaining the non-significant changes in female sterilization rates from 2019 to 2020. Some patients who had to delay female sterilization during this time elected for an LARC device as a bridge. The unprecedented stress of pregnancy, delivery, and financial hardship during the COVID-19 pandemic, along with increased caregiver efforts to offer immediate LARC, may contribute to increased postpartum LARC initiation. Unlike national trends of strained contraception access related to the pandemic,^2,3 this study did not see a change in overall postpartum contraception utilization inclusive of the discharge to 10 weeks’ postpartum period. It may be explained by early COVID-19 training protocols at UMMMC aimed to increase immediate postpartum contraception use in anticipation of postpartum telehealth.

Interestingly, the early postpartum group was less likely to receive any contraception at the in-person or telehealth OPPV during the early pandemic compared to 2019. However, sensitivity analysis of this model found no difference in contraception use across time points for in-person OPPVs. This finding can be explained by (1) smaller sample size after excluding telehealth individuals and (2) some contraception requiring in-person administration. Patients may have been dissatisfied with the limited contraceptive methods available through telehealth or patients intending to receive LARC or DMPA may have elected for an in-person OPPV.

In wave-1 of the COVID-19 pandemic, there was no decrease in OPPV access in this sample population, which was likely due to rapid expansion of telehealth services. Lower OPPV attendance rates by patients with public insurance is congruent with the nationwide trend with median state-reported Medicaid OPPV attendance rate at 61%, compared to 68% in this study.¹⁶ The ability to attend OPPVs disproportionately impacts socially and economically vulnerable patients, especially younger and non-white individuals.^17,18

Immediate postpartum LARC use is associated with improved maternal–child outcomes, in addition to financial benefits.^19,20 A cohort study demonstrated an association between public insurance reimbursement for immediate postpartum LARC with lower preterm birth, fewer low-birth-weight infants, and decrease in short-interval birth among non-Hispanic Black individuals.²¹ Immediate postpartum LARC insertion is estimated to save US$1263 per patient compared with insertion at the OPPV due to medical costs resulting from unintended pregnancy during the intervening postpartum period.²² Cost saving is especially beneficial during a pandemic when financial concerns and job instability was marked.² The restriction that most private health insurance does not reimburse immediate postpartum LARC was reflected in our study, as no privately insured patients received pre-discharge LARC. Expanding insurance policies to increase immediate postpartum LARC access can be a cost-effective way to improve maternal–child health outcomes.

Study strengths include an in-depth chart review of all patients, which increased the ability to identify contraceptive discussions, and diversity of the patient population at UMMMC. Our study has several limitations. One limitation is restricted access to review subjects’ non-UMMMC medical records, thus potentially underestimating postpartum OPPV and contraception utilization rates if patients sought care outside of the UMMMC system. A large percentage (23.6%, 117/495) of the sample did not attend an OPPV and their pre-discharge contraception method was used for analysis at 10 weeks’ postpartum. The immediate postpartum contraception use of patients who did not attend an OPPV is shown in Figure 2. Two assumptions were made: (1) pre-discharge contraception was continually used 10 weeks later (overestimates use) and (2) those who did not attend an OPPV did not receive prescription contraception from other clinics (underestimates use). There was no evidence of LARC removal or female sterilization reversal among patients who did not attend OPPV by 10 weeks’ postpartum, thus it is more likely that immediate postpartum LARC (n = 14) and female sterilization (n = 10) use reflects usage at 10 weeks’ postpartum. Furthermore, injection of pre-discharge DMPA, which lasts up to 13 weeks,²³ implies continued use at 10 weeks’ postpartum. The existing literature supports that people who do not attend their OPPV are 50%–300% less likely to use postpartum contraception.^24,25 Given that sensitivity analyses found no differences in overall contraception modes at 10 weeks’ postpartum of patients with OPPV attendance (n = 378) versus all patients (n = 495), we felt confident to include patients with no OPPV in the overall 10 weeks’ analysis.

A study limitation is that oral contraceptive, hormonal patch, and vaginal ring use data are based on prescriptions administered and may not reflect true use. The study is limited due to relatively small sample size due to the restricted sample study period resulting in the use of a pragmatic convenience sample. Another limitation is lack of analysis on patients’ primary language, as previous research has shown that women who spoke Spanish were less likely to recall being offered immediate postpartum LARC than English-speaking patients.²⁶ In this study, non-English-speaking patients may have received less or lower quality postpartum contraception counseling despite using phone interpreters, possibly leading to lower contraception use.

Implications for practice

The UMMMC obstetrics and gynecology department led several initiatives to minimize disruption to maternity and postpartum care in response to the pandemic. Telehealth was rapidly expanded to increase access to outpatient postpartum care but was limited in the scope of services and types of contraception prescribed. Telehealth OPPVs should continue to be offered as an alternative to patients who cannot attend in-person visits.

In March 2020, there was a department-wide training to increase immediate postpartum contraception uptake in anticipation of postpartum telehealth and restriction of elective surgical procedures. Obstetric providers initiating conversations about postpartum contraception during prenatal care is important for shared decision-making as it facilitates patients having adequate time to make informed family planning decisions.²⁷ Shared decision-making models with patient preferences at the center are important given significant equity issues including: (1) the disproportionate impacts of COVID-19 on populations marginalized by racism and socioeconomic disadvantages,²⁸ (2) the historical coercive reproductive practices in marginalized populations that fuels mistrust,²⁹ (3) provider bias in recommending LARC more often to low-income patients and people of color, in addition to government sterilization practices negatively impacting patient–provider therapeutic relationships.³⁰ We acknowledge immediate postpartum LARC was only offered to publicly insured patients due to aforementioned private insurance coverage restrictions. Providers should continue unbiased contraceptive counseling throughout prenatal care.

Conclusion

This retrospective cohort study of births at a central Massachusetts hospital in 2019 and 2020, showed that immediate postpartum LARC use increased three-fold during the COVID-19 pandemic wave 1, while overall use of contraception was unchanged at 10 weeks’ postpartum, compared to the same time period in 2019. There was no change in OPPV attendance between the two periods with the expansion of telehealth services. Although telehealth may improve postpartum care access, contraceptive methods that can be prescribed via telehealth are limited. The evaluation of contraceptive trends during the COVID-19 pandemic can help identify opportunities to increase access to effective contraception, such as the immediate postpartum period prior to hospital discharge. Strategies to improve access to contraception are necessary, and especially during pandemics and other disruptive events.

Footnotes

Not applicable.

Declarations

ORCID iD

Emily Chin

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