Barriers to Preferred Contraception Use in Mississippi

Abstract

Introduction:

Many Americans are not using the contraceptive method they prefer, but there has been limited study of how this may be related to health system barriers. We evaluated how such barriers to contraceptive care are related to unmet contraceptive preference in Mississippi and which contraceptive methods are preferred by those who report an unmet preference.

Materials and Methods:

Between September 2020 and February 2021, we used social media advertisements to recruit Mississippi residents 18–45 years of age, who were assigned female at birth, for an online survey. We asked respondents if they wanted to use a different contraceptive method or start using one, and if so, which method they preferred. We assessed barriers in the reproductive healthcare services environment (e.g., long wait for appointments, unaffordability or lack of insurance acceptance). We used multivariable-adjusted Poisson regression models to test the relationship between experiencing one or more barriers to reproductive healthcare and having an unmet contraceptive preference.

Results:

Among 462 eligible respondents, 37% had an unmet contraceptive preference. Most respondents (83%) reported one or more barriers to accessing office-based reproductive healthcare. Respondents who experienced a barrier had almost twice the prevalence of unmet preference as people who experienced no barrier (prevalence ratio 1.81, 95% confidence interval: 1.14–2.86). Among respondents with unmet preference, short-acting hormonal, long-acting reversible, and permanent methods were most desired.

Conclusion:

We find that nearly two-fifths of reproductive-aged Mississippians with capacity for pregnancy are not using their preferred contraceptive method. Structural barriers to care are very common and are significantly associated with experiencing unmet contraceptive preference, undermining reproductive autonomy.

Introduction

Many people in the United States¹ are not using the contraceptive method of their choice, which is considered unmet contraceptive preference. In 2019, an estimated 22% of sexually active reproductive-aged women at risk of unintended pregnancy in the United States would use a different contraceptive method in the absence of cost.¹ Unmet contraceptive preference contributes to contraceptive discontinuation and can lead to an unintended pregnancy or birth.^2

–5 In addition, unmet preference has been suggested as an important measure of reproductive autonomy and evidence of health system failure.^4,6 Historically, contraception scholarship and policy have focused on contraceptive use or nonuse, and there has been a recent emphasis on promoting highly effective methods, such as long-acting reversible contraception (LARC).⁷ Meeting people’s preferences for contraception, rather than achieving specific metrics for contraceptive use, promotes bodily and childbearing autonomy.^4,7,8 Individual-level characteristics have been found to be related to unmet contraceptive preference, including race and ethnicity, income, and current contraceptive method use.^1,2 However, the social-ecological model, which conceptualizes individuals as nested within contexts, suggests that institutional, community, and policy barriers are also related to unmet contraceptive preference.^9,10

People living in the United States face substantial contextual barriers to accessing and using contraception.^11,12 Cost has been the main system-level barrier addressed in prior studies on discrepancies between current and preferred method use,^1,13 but other health system factors (e.g., provider bias, method stocking problems, health system capacity) may also prevent people from using their preferred method.^5,14,15 Identifying health system barriers that impact access to and achievement of contraceptive preference can inform policy solutions that support people’s reproductive autonomy. This is increasingly important as people capable of pregnancy have lost access or face increased barriers to facility-based abortion care in states that banned abortion after the U.S. Supreme Court’s Dobbs decision—states that already had poor indicators of maternal health.¹⁶

Mississippi provides a useful setting in which to assess unmet contraceptive preferences and barriers to care. Mississippi residents capable of pregnancy face one of the most constrained reproductive health service landscapes in the country. Mississippi has not expanded Medicaid¹⁷ and 14% of women 18–64 years of age are uninsured, the fifth highest rate in the United States.¹⁸ In addition, 13% of Mississippi women ≥18 years of age report not being able to see a doctor in the last year due to cost, the fourth highest in all U.S. states and territories.¹⁹ Mississippi has a low ratio of contraceptive providers to population.²⁰ At the policy level, Mississippi is one of the states with the fewest policies and programs to support contraceptive access.²¹ Measuring unmet contraceptive preference and system-level factors that contribute to unmet preference can identify areas for health system improvement and illuminate where interventions and resources should be directed.

We sought to evaluate the level of unmet preferred contraceptive use in Mississippi, how structural barriers to contraceptive care are related to unmet contraceptive preference, and which contraceptive methods are preferred by those who are experiencing unmet contraceptive preference.

Material and Methods

Data collection

Between September 2020 and February 2021, we conducted an online survey with Mississippi residents assigned female at birth to assess their experiences accessing reproductive healthcare in their communities. We described our sampling and recruitment methods previously and summarize them briefly here.²² We recruited respondents through social media advertisements on Facebook, Instagram, and Craigslist. We placed advertisements in six geographic areas of Mississippi. We selected geographic areas purposively based on population size and demographic composition and input from community organizations focused on reproductive health, rights, and justice. The organizations highlighted the importance of including counties in the Mississippi Delta, given the well-documented health disparities in this region. Each geographic area included the main county of the metropolitan (or micropolitan) statistical area and a neighboring less populated, micropolitan (or rural) county, to capture diverse reproductive health service environments. The areas selected accounted for approximately 40% of Mississippi’s reproductive-aged female population.²³

Advertisements directed potential participants to a screening survey to determine eligibility. Respondents eligible for the study were Mississippi residents assigned female at birth, who were between 18 and 45 years of age and were not pregnant or desiring pregnancy in the next two years. To mitigate fraud, research staff reviewed each self-screening response for potential duplicates using e-mails, phone numbers, and IP addresses,²⁴ and we did not invite screening respondents to take the survey if we identified them as likely duplicates. Research staff e-mailed or texted eligible, nonduplicated respondents a personalized link to the online REDCap survey. As a further step to exclude fraudulent entries, we compared age and county of residence reported at screening to year of birth and zip code reported at the time of survey, respectively, and omitted responses that were inconsistent.²⁵ We provided nonfraudulent respondents who completed the survey $30.

The survey assessed barriers to accessing health care, current contraceptive use, and contraceptive method preference and took respondents approximately 15 minutes to complete.

Approval for the survey was granted by the University of Texas at Austin Institutional Review Board (Protocol ID 2020060116).

Measures

Primary independent variable: Health system barriers

To assess the structural barriers to reproductive healthcare that respondents had experienced, we asked how much respondents agreed or disagreed on a five-point Likert scale with the following six statements that have been used in prior studies of reproductive healthcare barriers²⁶: There is more than one good place to go to get women’s health care; it is easy to get to an office or clinic that provides women’s health care; it takes a long time to get an appointment; the office or clinic hours are not convenient; it is easy to find a place where you feel comfortable going to the office or clinic; and it is difficult to find a place that is affordable or accepts your insurance. We reverse coded items as needed to reflect difficulty accessing care and then dichotomized responses such that respondents who somewhat or strongly agreed with the statement experienced a barrier to care. We created an overall indicator of experiencing any structural barrier to reproductive healthcare, coded as one if a respondent reported one or more of the barriers and zero if they did not report any barrier.

Primary outcome: Unmet preference due to cost

We assessed unmet contraceptive preference using a measure included in prior studies.²⁶ We asked respondents who reported ever having had sex with a man: “If you could get any birth control method you wanted for free, would you want to use a different method?” Respondents who would switch methods or start using a method (for those not currently using a method) reported the method they wanted to use. We categorized the methods into permanent (including tubal ligation and a partner’s vasectomy), LARC (including intrauterine device and subdermal implant), short-acting hormonal (including pill, patch, ring, and injection), and coital-dependent methods (including barrier and fertility awareness methods). Respondents could also answer that they did not know what method they would use.

Other measures

We also collected respondents’ age in years, race and ethnicity, educational attainment, and insurance status. To measure income, we asked respondents to report the number of people living in their household, and then asked if their monthly household income was below or above 194% of the federal poverty line for that household size, making them eligible for Mississippi’s Medicaid family planning waiver.²⁷

Among respondents who had ever had sexual intercourse with a man, we assessed current contraceptive use by asking if they or their male partner were using any birth control method. If the respondent said no, we included a follow-up question to capture methods that may not have been considered: withdrawal/pulling out, fertility awareness, calendar, rhythm method, or other natural family planning, male condoms, and breastfeeding as birth control. We asked respondents who reported using a contraceptive method to select all methods they were using from a list, and then we classified their current method as the most effective method they reported using.

Analysis

We limited this analysis to respondents who were sexually active in a way that could result in pregnancy the year before taking the survey, had not had a hysterectomy, and had nonmissing values for all covariates of interest. We calculated the distribution of respondents’ demographic characteristics and contraceptive method used, according to whether they reported any barrier to reproductive healthcare. We computed the percentage of respondents who were not using their preferred contraceptive method and then calibrated this measure, using age and insurance status, to get an overall estimate for Mississippi-resident women (sample and state distributions can be found in Supplementary Table S1). Calibration is similar to poststratification weighting, but is used when only table margins (versus stratification cross-tabulation cells) are available, as is the case for sex-specific distributions of age group and insurance status in the most detailed state estimates from ACS.²⁸ Also, because the ACS did not ask questions about gender identity, we used the population of Mississippi residents who reported being female in our calibration estimates.

We report unadjusted and multivariable-adjusted Poisson regression assessing the relationship between reporting at least one barrier to care and unsatisfied contraceptive method preference. Models included robust sandwich error estimation and adjusted models controlled for age, race and ethnicity, insurance status, and income, which have previously been found to be related to unmet preference.^1,2 We also calculated the percentage of respondents who reported each of the six barriers to care and, in separate Poisson regression models with the above covariates, we assessed the relationship between each of the six barriers and not using one’s preferred method.

We calculate the percent of respondents in each demographic and contraceptive method group, who were not using their preferred contraceptive method. We then conduct a series of unadjusted Poisson regression models, each with a demographic variable as the independent variable and the use of preferred method as the dependent variable.

Finally, we examined the specific methods that people wanted to use, overall and by current method use. We conducted all analysis in R Statistical Software version 4.2.2.

Results

Of the 3,894 screening entries we received, we excluded 2,123 as likely fraudulent or duplicate entries and 1,111 did not meet the eligibility criteria. We invited the remaining 660 to complete the full survey. Among the 565 respondents who completed the survey, 77 were not sexually active in the last year, 15 had hysterectomies, and 11 had missing values on variables of interest, leaving 462 who met the criteria for this analytic sample.

Most respondents (n = 397; 86%) described themselves as straight, 65 (14%) identified as bisexual or “some other way,” and four (1%) reported their gender identity as nonbinary. The median age of the sample was 33 years. Half of respondents (52%) were non-Hispanic White, one-third were non-Hispanic Black (34%), and 43% had a bachelor’s degree or more education (Table 1). Most respondents (71%) had private insurance, 14% had public insurance, and 15% did not have insurance. Almost all respondents (92%) were using some form of contraception. Coital-dependent contraceptive methods were the most commonly used methods (30%), followed by short-acting hormonal methods (23%) and permanent methods (22%). Most (83%) respondents reported at least one barrier accessing office-based reproductive healthcare.

Table 1.

Demographic Characteristics of Survey Respondents, Mississippi 2020–2021

	Overall(n = 462)		Reported nobarrier/s tocare (n = 81)		Reportedbarriers tocare (n = 381)
	n	%	n	%	n	%
Age, years
18–24	84	18.2	11	13.6	73	19.2
25–29	87	18.8	11	13.6	76	19.9
30–34	101	21.9	16	19.8	85	22.3
35–39	98	21.2	23	28.4	75	19.7
40–45	92	19.9	20	24.7	72	18.9
Ethnicity and Race
Non-Hispanic White	246	53.2	38	46.9	208	54.6
Non-Hispanic Black	156	33.8	33	40.7	123	32.3
Non-Hispanic Other^a	38	8.2	6	7.4	32	8.4
Hispanic	22	4.8	4	4.9	18	4.7
Educational Attainment
High school, equivalent, or less	84	18.2	14	17.3	70	18.4
Some college or associates	180	39.0	25	30.9	155	40.7
Bachelors	106	22.9	22	27.2	84	22.0
Graduate school	92	19.9	20	24.7	72	18.9
Insurance type
Private Insurance	328	71.0	62	76.5	266	69.8
Public Insurance	66	14.3	14	17.3	52	13.6
No Insurance	68	14.7	5	6.2	63	16.5
Income eligible for Medicaid family planning waiver^b
Yes	270	58.4	43	53.1	227	59.6
Current contraceptive method use^c
Coital dependent	140	30.3	26	32.1	114	29.9
Short-acting hormonal	106	22.9	14	17.3	92	24.1
Permanent	101	21.9	19	23.5	82	21.5
Long-acting reversible	79	17.1	11	13.6	68	17.8
None	36	7.8	11	13.6	25	6.6

Other racial identity includes the following: American Indian/Alaska Native/First Nations n = 2; South East Asian n = 2; South Asian n = 4; More than one race n = 21; Other = 1; Prefer not to say = 8.

≤194% Federal Poverty Limit household income.

Coital-dependent methods include condoms, withdrawal, and fertility awareness methods; short-acting hormonal methods include the pill, patch, ring, and injection; permanent methods include tubal ligation and vasectomy; and long-acting methods include the intrauterine device and subdermal implant.

Health system barriers and unmet contraceptive preference

Overall, 37% (n = 172) of respondents were not using their preferred method due to cost. After calibrating the sample, an estimated 39% of sexually active Mississippians assigned female at birth between 18 and 45 years of age have an unmet contraceptive preference. Long wait times for appointments were the most common barrier, reported by 60% of the sample, followed by unaffordability or the provider not accepting their insurance (42%) and inconvenient office or clinic hours (36%; Table 2). In multivariable-adjusted Poisson regression models, respondents who experienced at least one barrier to office-based reproductive care had almost twice the prevalence of unmet contraceptive preference than people who experienced no barrier (prevalence ratio [PR]: 1.81, 95% confidence interval [CI]: 1.14–2.86). When considering each health system-level barrier in separate adjusted models, the barrier associated with the highest prevalence of unmet contraceptive preference was not being able to find a provider that was affordable or that accepted respondents’ insurance (PR in adjusted model: 1.65, 95% CI: 1.29–2.11). Inconvenient hours and affordability also remained significant after adjusting for confounding variables.

Table 2.

Percentage of Respondents Who Reported Barriers Accessing Reproductive Health Care and the Association with Unmet Contraceptive Preference (n = 462)

	n	%	% not using pref. method	Unadj. PR (95% CI)	Adj.^a PR (95% CI)
At least one barrier	381	82.5	40.9	2.07 (1.31, 3.27)	1.81 (1.14, 2.86)
Long wait for appointment	278	60.2	41.7	1.37 (1.06, 1.78)	1.29 (1.00, 1.66)
Unaffordability or lack of insurance acceptance	193	41.8	50.8	1.85 (1.45, 2.34)	1.65 (1.29, 2.11)
Inconvenient hours	165	35.7	44.2	1.33 (1.05, 1.68)	1.38 (1.09, 1.73)
Uncomfortable clinic or office environment	139	30.1	44.6	1.31 (1.03, 1.67)	1.11 (0.87, 1.41)
Difficulty getting to clinic or office	102	22.1	41.2	1.14 (0.87, 1.49)	1.02 (0.79, 1.33)
Few options for care	95	20.6	44.2	1.25 (0.96, 1.63)	1.03 (0.79, 1.34)

Prevalence ratio of unmet contraceptive preference, adjusting for age, race and ethnicity, insurance status, and income.

PR, Prevalence ratio; CI, confidence interval.

Characteristics associated with unmet preference due to cost

Compared to respondents 18–24 years of age, unmet contraceptive preference was less common among respondents 30–34 (PR: 0.58, 95% CI: 0.40–0.84), 35–39 (PR: 0.66, 95% CI: 0.46–0.93), and 40–45 years of age (PR: 0.68, 95% CI: 0.48–0.97; Table 3). Uninsured respondents also had a higher prevalence of unmet contraceptive preference than privately insured respondents (PR: 2.05, 95% CI: 1.62–2.58). The prevalence of unmet contraceptive preference was lowest among permanent method users (18%) and highest among coital-dependent method users (52%).

Table 3.

Characteristics Associated with Not Using One’s Preferred Method (n = 462)

	% not using preferred method	PR^b	(95% CI)
Age, years
18–24	51.2	1	(ref)
25–29	39.1	0.76	(0.55, 1.07)
30–34	29.7	0.58	(0.40, 0.84)
35–39	33.7	0.66	(0.46, 0.93)
40–45	34.8	0.68	(0.48, 0.97)
Ethnicity and Race
Non-Hispanic Black	35.0	1	(ref)
Non-Hispanic White	37.2	0.94	(0.72, 1.23)
Non-Hispanic Other	44.7	1.20	(0.80, 1.81)
Hispanic	50.0	1.35	(0.84, 2.15)
Insurance status
Private insurance	32.3	1	(ref)
Public insurance	31.8	0.99	(0.67, 1.45)
No insurance	66.2	2.05	(1.62, 2.58)
Income eligibility for Medicaid family planning^a
Not eligible	29.2	1	(ref)
Eligible	43.0	1.47	(1.14, 1.91)
Contraceptive method
Coital dependent	52.1	1	(ref)
Short-acting hormonal	37.7	0.72	(0.54, 0.97)
Permanent	17.8	0.34	(0.22, 0.54)
Long-acting reversible	34.2	0.66	(0.46, 0.93)
None	38.9	0.75	(0.48, 1.16)

Qualifying household income is ≤194% Federal Poverty Limit.

Prevalence Ratio, unadjusted.

PR, Prevalence ratio; CI, confidence interval.

Preferred method use

Among the 172 respondents who would change or start using contraceptive methods, 30% wanted to use a short-acting hormonal method, 28% wanted to use a LARC method, and 26% wanted to use a permanent method (Fig. 1). One in ten (10%) desired a coital-dependent method and 7% did not know what method they wanted to use. No respondent would switch to “no method.”

FIG. 1.

Patterns of current contraceptive method use and preferred contraceptive method among those with unmet contraceptive preference (n = 172).

Respondents most often desired a more effective method, with fewer than one in five respondents with unmet preference (n = 29; 17%) wanting to switch to a different method of the same method effectiveness category (e.g., from using an intrauterine device to an implant). Among LARC users who desired to change methods (n = 27), the largest share desired a permanent method (n = 12, 44%). Of hormonal short-acting method users who desired a different method (n = 40), 50% (n = 20) desired a LARC method and 13% (n = 5) desired a permanent method. Nearly, one-third (n = 23, 32%) of coital-dependent methods users with unmet preference (n = 73) desired to switch to short-acting hormonal methods, 29% (n = 21) desired permanent methods, and 23% (n = 17) desired LARC methods. Among respondents using no method and desiring to start using a method (14), 43% (n = 6) desired short-acting hormonal methods, 14% desired permanent methods (n = 2), and 14% (n = 2) desired a LARC method. Of 101 permanent method users (tubal ligation or partner’s vasectomy), 18 would switch methods. Over half of those who would change (10, 56%) would prefer a hormonal short-acting method and 22% (4) would switch to a different permanent method. For respondents who wanted to switch methods, nearly one in five of those who were not using any method (n = 3, 21%) or who were using a LARC method (n = 5, 19%) reported that they did not know what method they wanted to switch to; this was higher than the percentage reported by those using permanent methods (n = 1, 6%), coital-dependent methods (n = 3, 9%), and short-acting hormonal methods (n = 0, 0%).

Discussion

We estimate that 39% of sexually active Mississippi residents 18–45 years of age, who were assigned female at birth and were not pregnant or trying to become pregnant, would use a different contraceptive method (or start using one) if all methods were available at no cost. This is nearly twice as high as the 22% of U.S. women who reported not using their preferred method.¹ It is also higher than recent estimates for Ohio (25%) and Wisconsin (33%). This likely reflects the limited number of policies that Mississippi has enacted, which supports contraception access.^2,21,29

Our assessment of health system barriers reveals that unmet contraceptive preference was most often related to costs, both not being able to afford the method and insurance not being accepted. Relatedly, our analysis found that uninsured respondents were more likely to experience unmet contraceptive preference than those with private or public insurance. This is likely related to the fact that Mississippi has not expanded Medicaid¹⁷ and has provided limited financial resources to support care at safety net health centers for uninsured and underinsured residents.^21,30 Although respondents without insurance more often reported an unmet contraceptive preference, nearly one-third of private and publicly insured respondents also reported this, indicating other system-level barriers to care for these groups. This may include copays and coinsurance and a limited number of providers in Mississippi, who accept Medicaid for specific contraceptive methods only.^31,32

The most common barrier to reproductive healthcare was experiencing long wait times for appointments. This aligns with prior findings^32,33 and likely reflects the shortage of reproductive healthcare providers in Mississippi.³⁴ In communities with a shortage of providers, the existing providers may work at many clinics throughout the week, contributing to inconvenient clinic or office hours and long wait times for an appointment. The relationship between inconvenient hours and unsatisfied contraceptive preference due to cost, controlling for poverty and insurance status, could be due to respondents generalizing “costs” to include time burdens, travel and childcare costs incurred attending appointments, and lost wages from taking time off work.

We find that respondents often wanted to use a method that was more effective than their current method—methods that often have higher upfront costs, especially if they are not covered by insurance. However, some respondents expressed interest in methods that were similarly (or less) effective than their current method. This finding is in agreement with prior literature showing that people consider multiple factors in deciding on their preferred contraceptive method, such as ease of use, being able to stop use without visiting a provider, minimizing side effects, and avoiding hormones.³⁵ Support for the idea that people consider multiple factors is reflected by the finding that coital-dependent method users more often prefer permanent methods over LARC methods, indicating a preference for methods that do not contain hormones. These findings also demonstrate the need for health insurers and providers to make the full range of contraceptive options available at no cost for people capable of becoming pregnant or causing a pregnancy to ensure reproductive autonomy.³⁶ Providing only some methods at no cost is not enough to ensure reproductive autonomy and can be coercive.⁷

While we did not find differences in preferred method use by race, the systematic financial oppression of pregnancy-capable people in Mississippi should not be seen as unrelated to systemic racism. States with higher proportion of Black or Hispanic population have significantly lower discretionary Medicaid spending,³⁷ and states with a higher proportion of Black residents have often rejected Medicaid expansion more so than other states.³⁸

Implications for policy and practice

Expanding Medicaid and thereby increasing the number and percent of people who have health insurance coverage could decrease unmet contraceptive need in Mississippi. Furthermore, respondents cited not being able to find someone who takes their insurance. Increasing the reimbursement rate and reducing administrative burdens of Medicaid could encourage providers to accept Medicaid and make this experience less common. To ensure that a full range of contraceptive options are widely available, providers should be trained in the insertion of LARC methods, and facilities should have all methods in stock. In addition, the state should ensure that health insurers are compliant with the contraceptive coverage mandate in the Affordable Care Act to provide coverage for a broad range of methods.³² Finally, the state of Mississippi should increase financial support to safety net providers and programs that would increase the number of facilities and providers and eliminate or decrease costs, such as copays.³²

Limitations and strengths

The results of this survey may not be generalizable to the population of reproductive-aged Mississippi residents assigned female at birth because we recruited respondents through social media rather than selecting from a known sampling frame. However, sample demographics closely mirror those of women in the state,^18,23 and we calibrated our estimate of unmet contraceptive preference to better reflect the age and insurance distribution in Mississippi. Second, the question stem used to measure unmet contraceptive preference specifies desiring to change methods due to cost. This question stem has been used in the other studies,^1,13 but it may not fully capture the percentage of people not using their preferred method. People experience other, nonfinancial, barriers to care, and therefore, the prevalence of general unmet preference may be higher. In addition, people who have more limited knowledge about contraceptive options other than the method they are using may have selected that they would not change methods, but might consider switching if they had more information. Since only 172 respondents in our sample would prefer a different method than what they were using, the analysis of this group by current method type and preferred method type results in small cell sizes. Finally, the survey was not open to people younger than 18 years, so we do not have information about teens, a group with unique and unmet needs.³⁹

Despite these limitations, this study illuminates important barriers to contraceptive access in states that have poor health outcomes and health service shortages. The survey reached a substantial number of respondents in a time when in-person recruitment was almost impossible due to the COVID-19 pandemic.

Conclusion

Using data from an online survey of Mississippi residents assigned female at birth, we found that both health system barriers to reproductive healthcare and unmet contraceptive preference due to cost are prevalent. Because these barriers undermine reproductive autonomy, health service and policy changes are needed to reduce unmet preference. These improvements include expanding Medicaid, eliminating or decreasing out-of-pocket costs, and increasing the number of providers and facilities.

Footnotes

Authors’ Contributions

K.L. and K.W. contributed to the survey design and data collection. Nagle, White, and Lerma conceptualized the research idea. A.N. performed the analysis. All authors contributed to the interpretation of results. A.N. wrote the first draft of the article and lead revisions. All authors commented on previous versions of the article and read and approved the final article.

Ethics Approval

Approval was granted by the Ethics Committee of the University of Texas at Austin (Protocol ID 2020060116).

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Availability of Data and Material

The data that support the findings of this study may be available from the study’s principal investigator (K.W.) upon reasonable request.

Author Disclosure Statement

The authors have no relevant financial or nonfinancial interests to disclose.

Funding Information

This study was funded by a grant from the David and Lucile Packard Foundation and by a center grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2CHD042849) awarded to the Population Research Center at the University of Texas at Austin. The funders played no role in study design, in the collection, analysis, and interpretation of data, in the writing of the report, or in the decision to submit the article for publication.

Supplementary Material

Supplementary Table S1

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