Low-Income Texas Women Do Not Get the Contraception They Want at Their Six-Week Postpartum Checkup

by Kate Coleman-Minahan and Joseph E. Potter
December, 2018

The postpartum period is a challenging time for women. They are recovering physically and emotionally from labor and delivery while caring for a new infant and sometimes older children. The routine postpartum visit, commonly known as the “six-week checkup,” is an opportunity to provide women with the contraception they desire. Yet our new research shows that low-income Texas women face numerous challenges getting the contraception they want at the first postpartum visit.  

Experts recommend that women have access to their desired method of contraception as soon after delivery as they desire. However, roughly half of women are using no method or less effective methods such as condoms or withdrawal 3 months postpartum and many are not using their desired method.  When women are unable to access and use the method of contraception they desire, it puts them at risk of becoming pregnant when they do not want to be. Providing women with the means to plan their families on a timely basis is crucial to the health and well-being of women, children, and their families. 

Most prior research focuses on women’s use of contraception, not whether they can access their desired method of contraception; this study focuses specifically on whether women are getting the contraception they want and the barriers they face in getting the method they would like to be using.  

Methods and Sample 

The Texas Policy Evaluation Project, a research group based at The University of Texas at Austin, surveyed women at three months postpartum who had given birth to a healthy child at eight hospitals across six Texas cities. Public or no insurance covered their deliveries; and none of them wanted another child for at least two years. We asked 685 women, 80% of whom are Hispanic and 39% foreign-born, who desired reversible contraception, what contraceptive method they received at their first postpartum visit, usually within six weeks after delivery. Next, we asked what method they wanted to receive at their visit and the reasons why they were unable to receive it. 

Study Results: Access to Contraception is Low 

Sixty-six percent of our participants did not receive their desired method or a prescription for their desired method of contraception at the first postpartum visit. While some women (8%) left the visit with a form of contraception they did not want, over half (58%) left with no method at all. Women who desired the IUD or implant, two of the most effective and long-lasting forms of contraception, faced greater barriers as only 10% of women desiring these methods received them at the first visit.

Although some women were able to overcome multiple barriers to contraception, others never received the method they desired. By three months postpartum, the women who did not receive the contraception they wanted at the six-week visit were half as likely to be using it as the women who did receive it (41% versus 86%). Women who were not using their desired method were frequently using less-effective methods of contraception. These findings demonstrate that barriers to contraception at the first postpartum visit result in greater use of less-effective contraception or no contraception among postpartum women who do not wish to become pregnant, increasing the likelihood of pregnancy.   

Clinic Barriers 

Thirty-seven percent of women were instructed to return for a second visit to obtain their desired method. Some were told the clinic did not provide the method at all or had to order the method. Ana, 29 year-old mother of two explained, “I asked him [doctor] about the IUD, and he suggested the pill. But I … wanted something that lasts longer. He said that I had to look somewhere else to get birth control because he doesn’t do it there at his office. But he didn’t recommend anywhere to go; he said I’d have to look around.” Clinics that do not offer the method and do not provide referrals place additional burdens on women who are caring for a new infant and recovering from delivery to not only make an additional appointment but spend time and energy locating a clinic that provides their method. 

Two-thirds of women whose clinician told them they were not eligible for their desired method due to health reasons received inaccurate contraceptive counseling and were indeed eligible for the method according to current Centers for Disease Control medical guidelines. Maria, a 31 year–old mother of three recalled she didn’t receive the implant she wanted: “I hadn’t gotten my period and they told me to use the injection. The doctor told me I have to use the injection three times and then I can use [the IUD].” Many inaccuracies centered on misconceptions about how contraception affects breastfeeding or the need for menstruation to return before starting a particular birth control method. Although we do not know why clinicians are providing inaccurate information, we did find that uninsured women were more likely to receive inaccurate counseling suggesting clinicians may use inaccurate medical reasons to discourage women from choosing methods expensive to the clinic. 

Some women recalled their clinician did not provide enough information about contraception for them to make a decision or obtain it, and others were discouraged from or pressured into particular methods: Aliyah, a 25-year-old mother of two recalled that the clinician “brushed me off when I wanted the implant, and said I needed to take the pill.” 

Cost Barriers 

Highly-effective contraception, such as the IUD and contraceptive implant, has a prohibitive out-of-pocket sticker price, with IUD costs sometimes exceeding $1,000. Even though low-income patients often qualify for discounts, applying for discounts requires at least one additional visit to fill out extensive paperwork and provide documents that is often challenging to navigate, creating delays in access. Nineteen-year-old Lizbeth reported, “I only wanted the IUD. They told me that I had to make another appointment to apply for discounts in order to get it for free, [and] that I would only pay for the copay. I made the second appointment for the discount, [but] I didn’t have some of the required documents, [and] they told me I couldn’t apply without them.” The financial discount may lower cost, but many women reported that the process of obtaining those discounts created additional barriers.  

Multiple participants reported their insurance ended before they could access contraception. In Texas, women with Pregnancy Medicaid lose their insurance coverage eight weeks after delivery, and undocumented women, whose births are often covered under CHIP Perinate, do not have any insurance coverage for contraception. An 18-year old mother of two wanted an implant at the first postpartum visit but was told “I needed to make another appointment, but now the insurance doesn’t cover me anymore.” She was using condoms to prevent pregnancy three months after delivery, a method much less effective at preventing pregnancy than her desired implant. 

Policy Implications 

• Expand Pregnancy Medicaid coverage to six-months postpartum, rather than eight weeks 
• Expand Pregnancy Medicaid to cover undocumented women and thus provide undocumented women access to postpartum contraception  
• Improve financial reimbursement to healthcare facilities providing IUDs and implants 

Clinical Implications 

• Create quality clinical care standards that include stocking all methods of reversible contraception and provision of same-day access to these methods  
• Ensure clinicians use the CDC’s Medical Eligibility Criteria when assessing medical reasons women cannot use certain types of contraception.  
• Increase clinician training on patient-centered, accurate, contraceptive counseling 
• Provide more timely and flexible appointments for postpartum women 
• Clinics providing income-based discounts could streamline the application process prior to the six-week postpartum visit, and women can receive their desired method at that visit 

Suggested Citation

Coleman-Minahan, K., Dillaway, C., Canfield, C., Kuhn, D.M., Strandberg, K.S., & Potter, J.E. (2018). Low-income Women’s Experiences Accessing Contraception at the First Postpartum Visit in Texas. Perspectives on Sexual and Reproductive Health. In-press. doi:10.1363/psrh.12083