Objective
Postpartum contraception is a highly effective clinical intervention that can help women achieve their personal goals and improve population health outcomes, including healthy birth spacing. Social determinants of health—the conditions in which people live, work, and play—can affect health outcomes, , including maternity outcomes. Social determinants like transportation, housing quality, childcare, and structural racism may plausibly shape individuals’ postpartum contraceptive preferences and access, but such effects are understudied. The Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI) is increasingly being used as a population-level indicator of social determinants of health. The SVI measures a community’s resilience to human suffering and financial loss by integrating 15 census variables to generate composite scores across the following 4 themes: socioeconomic status; household composition and disability; minority status and language; and housing type and transportation, with higher scores indicating greater vulnerability. We evaluated if living in census tracts with high social vulnerability is associated with the odds of postpartum long-acting reversible contraceptive (LARC) and sterilization use.
Study Design
This retrospective cohort analysis used administrative claims data from a statewide collaborative quality initiative. We identified childbirth episodes from January 2016 to December 2019 and excluded hospitals with <50 deliveries (n=4). Outcomes included LARC and sterilization use by 60 days postpartum. We fit multivariable logistic regressions to evaluate associations between the outcomes and exposure to the highest quintile SVI by theme and controlling for patient characteristics (age, number of chronic conditions, mode of delivery, birth year, region, and payer type). Regression models used hospital-fixed effects to keep the average effects of each hospital constant. The study was approved by the University of Michigan Institutional Review Board.
Results
The final cohort included 140,345 delivery episodes among 130,147 women (44% publicly insured) who delivered at 79 hospitals ( Supplemental Table 1 ). By 60 days postpartum, LARC use and sterilization use were initiated after 8.0% and 8.3% of delivery episodes, respectively. Individuals with the highest quintile of socioeconomic vulnerability (adjusted odds ratio [AOR], 1.14; 95% confidence interval [CI], 1.03–1.26) and minority status and language vulnerability (AOR, 1.12; 95% CI, 1.05–1.20) were more likely to use LARCs, whereas those with the highest household composition vulnerability were less likely (AOR, 0.76; 95% CI, 0.67–0.87). Housing/transportation vulnerability was not associated with LARC utilization (AOR, 1.01; 95% CI, 0.90–1.14) ( Supplemental Table 2 ; Figure ). Sterilization use was less likely to be taken up by those with the highest socioeconomic vulnerability (AOR, 0.87; 95% CI, 0.79–0.96) and minority status/language vulnerability (AOR, 0.85; 95% CI, 0.79–0.93) and more likely to be taken up by those with the highest housing/transportation vulnerability (AOR, 1.28; 95% CI, 1.14–1.44) and household composition vulnerability (AOR, 1.23; 95% CI, 1.10–1.38).
Conclusions
We observed independent associations between postpartum contraceptive use and social vulnerability, advancing similar findings from a single-center study of 8654 individuals linking neighborhood deprivation with fulfillment of the desired postpartum sterilization requests. Our findings suggest that structural factors—such as distance to clinic, fees for parking and transportation, clinic hours, childcare access, ability to miss work to seek healthcare, and out-of-pocket costs for healthcare—may affect postpartum contraceptive use. Of note, our analysis was unable to fully disentangle the effects of individual-level factors from the community-level factors (eg, the higher likelihood of LARC use and lower likelihood of sterilization among individuals living in neighborhoods with greater minority status and language vulnerability could reflect neighborhood-level healthcare access or the preferences of individuals living in these communities or both). Future research is needed to better elucidate the mechanisms by which social determinants shape individuals’ contraceptive preferences, access, and utilization after childbirth. Nonetheless, our current findings suggest that interventions seeking to improve postpartum contraceptive use and birth spacing cannot focus on healthcare delivery alone but should also consider the structural factors that affect women’s reproductive goals, contraceptive access, and contraceptive preferences after childbirth.
Appendix
| Characteristic | OverallN=140,345 | LARC utilization by 60 d postpartum n=11,292 | Sterilization utilization by 60 d postpartum n=11,611 |
|---|---|---|---|
| Age, y | |||
| 18–20 | 8557 (6.1) | 865 (7.7) | 13 (0.1) |
| 21–30 | 78,236 (55.7) | 6945 (61.5) | 5094 (43.9) |
| 31–40 | 51,481 (36.7) | 3379 (29.9) | 6091 (52.5) |
| 41–44 | 2071 (1.5) | 103 (0.9) | 413 (3.6) |
| Chronic conditions | |||
| 0 | 111,325 (79.3) | 8749 (77.5) | 8006 (69) |
| 1 | 22,832 (16.3) | 1995 (17.7) | 2579 (22.2) |
| ≥2 | 6188 (4.4) | 548 (4.9) | 1026 (8.8) |
| Birth year | |||
| 2016 | 32,161 (22.9) | 2385 (21.1) | 2266 (19.5) |
| 2017 | 35,924 (25.6) | 2992 (26.5) | 3175 (27.3) |
| 2018 | 36,161 (25.8) | 2847 (25.2) | 3060 (26.4) |
| 2019 | 36,099 (25.7) | 3068 (27.2) | 3110 (26.8) |
| Michigan region | |||
| East/Mid | 30,120 (21.5) | 3469 (30.7) | 2960 (25.5) |
| Detroit | 2098 (1.5) | 104 (0.9) | 213 (1.8) |
| Southeast | 4927 (3.5) | 446 (3.9) | 594 (5.1) |
| West | 26,810 (19.1) | 2280 (20.2) | 2823 (24.3) |
| North | 14,248 (10.2) | 1421 (12.6) | 880 (7.6) |
| Upper Peninsula | 62,142 (44.3) | 3572 (31.6) | 4141 (35.7) |
| Payer type | |||
| Commercial PPO/HMO | 78,022 (55.6) | 5942 (52.6) | 4109 (35.4) |
| Medicaid/Medicare | 62,323 (44.4) | 5350 (47.4) | 7502 (64.6) |
| Mode of delivery | |||
| Vaginal | 79,029 (56.3) | 6585 (58.3) | 1148 (9.9) |
| Cesarean delivery | 61,316 (43.7) | 4707 (41.7) | 10,463 (90.1) |
| SVI theme (top quintile) | |||
| Socioeconomic status | 13,736 (9.8) | 876 (7.8) | 1101 (9.5) |
| Household composition | 6901 (4.9) | 370 (3.3) | 647 (5.6) |
| Minority status/language | 14,756 (10.5) | 1170 (10.4) | 903 (7.8) |
| Housing/transportation | 4462 (3.2) | 356 (3.2) | 442 (3.8) |
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