Neighbourhood socioeconomic position, prenatal care and fulfilment of postpartum permanent contraception: Findings from a multisite cohort study.

ABSTRACT

Introduction: Research suggests neighbourhood socioeconomic vulnerability is negatively associated with women's likelihood of receiving adequate prenatal care and achieving desired postpartum permanent contraception. Receiving adequate prenatal care is linked to a greater likelihood of achieving desired permanent contraception, and access to such care may be critical for women with Medicaid insurance given that the federally mandated Medicaid sterilization consent form must be signed at least 30 days before the procedure. We examined whether adequacy of prenatal care mediates the relationship between neighbourhood socioeconomic position and postpartum permanent contraception fulfilment, and examined moderation of relationships by insurance type. Methods: This secondary analysis of a retrospective cohort study examined 3012 Medicaid or privately insured individuals whose contraceptive plan at postpartum discharge was permanent contraception. Path analysis estimated relationships between neighbourhood socioeconomic position (economic hardship and inequality, financial strength and educational attainment) and permanent contraception fulfilment by hospital discharge, directly and indirectly through adequacy of prenatal care. Multigroup testing examined moderation by insurance type. Results: After adjusting for age, parity, weeks of gestation at delivery, mode of delivery, race, ethnicity, marital status and body mass index, having adequate prenatal care predicted achieving desired sterilization at discharge (ß = 0.065, 95% confidence interval [CI] 0.011, 0.117). Living in neighbourhoods with less economic hardship (indirect effect -0.007, 95% CI -0.015, -0.001), less financial strength (indirect effect -0.016, 95% CI -0.030, -0.002) and greater educational attainment (indirect effect 0.012, 95% CI 0.002, 0.023) predicted adequate prenatal care, in turn predicting achievement of permanent contraception by discharge. Insurance status conditioned some of these relationships. Conclusion: Contact with the healthcare system via prenatal care may be a mechanism by which neighbourhood socioeconomic disadvantage affects permanent contraception fulfilment, particularly for patients with Medicaid. To promote reproductive autonomy and healthcare equity, future inquiry and policy might closely examine how neighbourhood social and economic characteristics interact with Medicaid mandates.