The impact of contraceptive access on high school graduation.

Does access to the full range of contraceptive methods increase young women's educational attainment? Family planning programs are often justified by claims that it does, but contemporary evidence is unexpectedly weak. We use a natural experiment afforded by a 2009 Colorado policy change to assess the impact of expanded access to contraception on women's high school graduation. Linking survey and Census data, we follow a population-representative U.S. sample, including large subsamples of young women living in Colorado in 2010 and in comparison states. Using a difference-in-differences design, we find expansion of access to contraception was associated with a statistically significant 1.66 percentage-point increase in high school graduation. This increase in graduation represents a 14% decrease in the baseline percentage not graduating high school before the policy change. Results are robust to a variety of sensitivity tests. Our findings indicate that improving access to contraception increases young women's human capital formation.

Contraception After Delivery Among Publicly Insured Women in Texas: Use Compared With Preference.

OBJECTIVE: To assess women's preferences for contraception after delivery and to compare use with preferences. METHODS: In a prospective cohort study of women aged 18-44 years who wanted to delay childbearing for at least 2 years, we interviewed 1,700 participants from eight hospitals in Texas immediately postpartum and at 3 and 6 months after delivery. At 3 months, we assessed contraceptive preferences by asking what method women would like to be using at 6 months. We modeled preference for highly effective contraception and use given preference according to childbearing intentions using mixed-effects logistic regression testing for variability across hospitals and differences between those with and without immediate postpartum long-acting reversible contraception (LARC) provision. RESULTS: Approximately 80% completed both the 3- and 6-month interviews (1,367/1,700). Overall, preferences exceeded use for both-LARC: 40.8% (n=547) compared with 21.9% (n=293) and sterilization: 36.1% (n=484) compared with 17.5% (n=235). In the mixed-effects logistic regression models, several demographic variables were associated with a preference for LARC among women who wanted more children, but there was no significant variability across hospitals. For women who wanted more children and had a LARC preference, use of LARC was higher in the hospital that offered immediate postpartum provision (P<.035) as it was for U.S.-born women (odds ratio [OR] 2.08, 95% CI 1.17-3.69) and women with public prenatal care providers (OR 2.04, 95% CI 1.13-3.69). In the models for those who wanted no more children, there was no significant variability in preferences for long-acting or permanent methods across hospitals. However, use given preference varied across hospitals (P<.001) and was lower for black women (OR 0.26, 95% CI 0.12-0.55) and higher for U.S.-born women (OR 2.32, 95% CI 1.36-3.96), those 30 years of age and older (OR 1.82, 95% CI 1.07-3.09), and those with public prenatal care providers (OR 2.04, 95% CI 1.18-3.51). CONCLUSION: Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of health care provider and system-level barriers. Expansion of immediate postpartum LARC provision as well as contraceptive coverage for undocumented women could reduce the gap between preference and use.

Women's Knowledge of and Support for Abortion Restrictions in Texas: Findings from a Statewide Representative Survey.

CONTEXT: States have passed numerous laws restricting abortion, and Texas passed some of the most restrictive legislation between 2011 and 2013. Information about women's awareness of and support for the laws' provisions could inform future debates regarding abortion legislation. METHODS: Between December 2014 and January 2015, some 779 women aged 18-49 participated in an online, statewide representative survey about recent abortion laws in Texas. Poisson regression analysis was used to assess correlates of support for a law that would make obtaining an abortion more difficult. Women's knowledge of specific abortion restrictions in Texas and reasons for supporting these laws were also assessed. RESULTS: Overall, 31% of respondents would support a law making it more difficult to obtain an abortion. Foreign-born Latinas were more likely than whites to support such a law (prevalence ratio, 1.5), and conservative Republicans were more likely than moderates and Independents to do so (2.3). Thirty-six percent of respondents were not very aware of recent Texas laws, and 19% had never heard of them. Among women with any awareness of the laws, 19% supported the requirements; 42% of these individuals said this was because such laws would make abortion safer. CONCLUSIONS: Many Texas women of reproductive age are unaware of statewide abortion restrictions, and some support these requirements because of misperceptions about the safety of abortion. Advocates and policymakers should address these knowledge gaps in efforts to protect access to legal abortion.

Effect of Removal of Planned Parenthood from the Texas Women's Health Program.

BACKGROUND: Texas is one of several states that have barred Planned Parenthood affiliates from providing health care services with the use of public funds. After the federal government refused to allow (and courts blocked) the exclusion of Planned Parenthood affiliates from the Texas Medicaid fee-for-service family-planning program, Texas excluded them from a state-funded replacement program, effective January 1, 2013. We assessed rates of contraceptive-method provision, method continuation through the program, and childbirth covered by Medicaid before and after the Planned Parenthood exclusion. METHODS: We used all program claims from 2011 through 2014 to examine changes in the number of claims for contraceptives according to method for 2 years before and 2 years after the exclusion. Among women using injectable contraceptives at baseline, we observed rates of contraceptive continuation through the program and of childbirth covered by Medicaid. We used the difference-in-differences method to compare outcomes in counties with Planned Parenthood affiliates with outcomes in those without such affiliates. RESULTS: After the Planned Parenthood exclusion, there were estimated reductions in the number of claims from 1042 to 672 (relative reduction, 35.5%) for long-acting, reversible contraceptives and from 6832 to 4708 (relative reduction, 31.1%) for injectable contraceptives (P<0.001 for both comparisons). There was no significant change in the number of claims for short-acting hormonal contraceptive methods during this period. Among women using injectable contraceptives, the percentage of women who returned for a subsequent on-time contraceptive injection decreased from 56.9% among those whose subsequent injections were due before the exclusion to 37.7% among those whose subsequent injections were due after the exclusion in the counties with Planned Parenthood affiliates but increased from 54.9% to 58.5% in the counties without such affiliates (estimated difference in differences in counties with affiliates as compared with those without affiliates, -22.9 percentage points; P<0.001). During this period in counties with Planned Parenthood affiliates, the rate of childbirth covered by Medicaid increased by 1.9 percentage points (a relative increase of 27.1% from baseline) within 18 months after the claim (P=0.01). CONCLUSIONS: The exclusion of Planned Parenthood affiliates from a state-funded replacement for a Medicaid fee-for-service program in Texas was associated with adverse changes in the provision of contraception. For women using injectable contraceptives, there was a reduction in the rate of contraceptive continuation and an increase in the rate of childbirth covered by Medicaid. (Funded by the Susan T. Buffett Foundation.).

Unmet demand for highly effective postpartum contraception in Texas.

OBJECTIVES: We aimed to assess women's contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth. METHODS: We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18-44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery. RESULTS: At 6 months postpartum, 13% of women were using an intrauterine device or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using long-acting reversible contraception (LARC). CONCLUSIONS: This study shows a considerable preference for LARC and permanent methods at 6 months postpartum. However, there is a marked discordance between women's method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception. IMPLICATIONS: In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at 6 months postpartum. Women's contraceptive needs could be better met by counseling about all methods, by reducing cost barriers and by making LAPM available at more sites.

Hospital variation in postpartum tubal sterilization rates in California and Texas.

OBJECTIVE: To estimate variation across hospitals in the rate of postpartum sterilization. METHODS: All hospitals with deliveries in California and Texas in 2009 were included. Proportion of live singleton deliveries with postpartum sterilization was calculated by hospital, insurance status (Medicaid compared with private insurance), type of delivery, and state. RESULTS: Within each insurance status in California and Texas, we found wide variations across hospitals in postpartum tubal sterilization rates. This variability was not explained by disparities in hospital cesarean delivery rates. Some, but not all, of this variation was attributable to the absence of sterilizations in Catholic hospitals. Overall, postpartum tubal sterilization rates were higher in Texas than in California (10.2% compared with 6.7%), and this difference was found among both public insurance and private insurance patients. Interval sterilizations were more frequent in California, but the difference was not large enough to offset the difference in postpartum sterilization. CONCLUSIONS: The variation in postpartum tubal sterilization rates across hospitals is substantial and exists even among hospitals without religious affiliations. Large-scale studies are needed to assess the demand for, and the barriers to, obtaining postpartum sterilization. LEVEL OF EVIDENCE: II.

Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: follow-up of a randomized trial among children at age 12 years.

OBJECTIVE: To test, among an urban primarily African American sample, the effects of prenatal and infancy home visiting by nurses on mothers' fertility, partner relationships, and economic self-sufficiency and on government spending through age 12 years of their firstborn child. DESIGN: Randomized controlled trial. SETTING: Public system of obstetric and pediatric care in Memphis, Tennessee. PARTICIPANTS: A total of 594 urban primarily African American economically disadvantaged mothers (among 743 who registered during pregnancy). Intervention Prenatal and infancy home visiting by nurses. MAIN OUTCOME MEASURES: Mothers' cohabitation with and marriage to the child's biological father, intimate partner violence, duration (stability) of partner relationships, role impairment due to alcohol and other drug use, use and cost of welfare benefits, arrests, mastery, child foster care placements, and cumulative subsequent births. RESULTS: By the time the firstborn child was 12 years old, nurse-visited mothers compared with control subjects reported less role impairment owing to alcohol and other drug use (0.0% vs 2.5%, P = .04), longer partner relationships (59.58 vs 52.67 months, P = .02), and greater sense of mastery (101.04 vs 99.60, P = .005). During this 12-year period, government spent less per year on food stamps, Medicaid, and Aid to Families with Dependent Children and Temporary Assistance for Needy Families for nurse-visited than control families ($8772 vs $9797, P = .02); this represents $12 300 in discounted savings compared with a program cost of $11 511, both expressed in 2006 US dollars. No statistically significant program effects were noted on mothers' marriage, partnership with the child's biological father, intimate partner violence, alcohol and other drug use, arrests, incarceration, psychological distress, or reports of child foster care placements. CONCLUSION: The program improved maternal life course and reduced government spending among children through age 12 years.

Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial.

OBJECTIVE: Our goal was to test the effect of prenatal and infancy home visits by nurses on mothers' fertility and children's functioning 7 years after the program ended at child age 2. METHODS: We conducted a randomized, controlled trial in a public system of obstetric and pediatric care. A total of 743 primarily black women <29 weeks' gestation, with previous live births and at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed), were randomly assigned to receive nurse home visits or comparison services. Primary outcomes consisted of intervals between births of first and second children and number of children born per year; mothers' stability of relationships with partners and relationships with the biological father of the child; mothers' use of welfare, food stamps, and Medicaid; mothers' use of substances; mothers' arrests and incarcerations; and children's academic achievement, school conduct, and mental disorders. Secondary outcomes were the sequelae of subsequent pregnancies, women's employment, experience of domestic violence, and children's mortality. RESULTS: Nurse-visited women had longer intervals between births of first and second children, fewer cumulative subsequent births per year, and longer relationships with current partners. From birth through child age 9, nurse-visited women used welfare and food stamps for fewer months. Nurse-visited children born to mothers with low psychological resources, compared with control-group counterparts, had better grade-point averages and achievement test scores in math and reading in grades 1 through 3. Nurse-visited children, as a trend, were less likely to die from birth through age 9, an effect accounted for by deaths that were attributable to potentially preventable causes. CONCLUSIONS: By child age 9, the program reduced women's rates of subsequent births, increased the intervals between the births of first and second children, increased the stability of their relationships with partners, facilitated children's academic adjustment to elementary school, and seems to have reduced childhood mortality from preventable causes.