Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine

Abstract

Objective:

Preliminary findings from selected health systems revealed interruptions in reproductive health care services due to the COVID-19 pandemic. We estimated changes in postpartum contraceptive provision associated with the start of the COVID-19 pandemic in Maine.

Methods:

We used the Maine Health Data Organization’s All Payer Claims Database for deliveries from October 2015 through March 2021 (n = 45 916). Using an interrupted time-series analysis design, we estimated changes in provision rates of long-acting reversible contraception (LARC), permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic. We performed 6- and 12-month analyses (April 2020–September 2020, April 2020–March 2021) as compared with the reference period (October 2015–March 2020). We used Poisson regression models to calculate level-change rate ratios (RRs) and 95% CIs.

Results:

The 6-month analysis found that provision of LARC (RR = 1.89; 95% CI, 1.76-2.02) and moderately effective contraception (RR = 1.51; 95% CI, 1.33-1.72) within 3 days of delivery increased at the start of the COVID-19 pandemic, while provision of LARC (RR = 0.95; 95% CI, 0.93-0.97) and moderately effective contraception (RR = 1.08; 95% CI, 1.05-1.11) within 60 days of delivery was stable. Rates of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased. RRs from the 12-month analysis were generally attenuated.

Conclusion:

Disruptions in postpartum provision of permanent contraception occurred at the beginning of the COVID-19 pandemic in Maine. Public health policies should include guidance for contraceptive provision during public health emergencies and consider designating permanent contraception as a nonelective procedure.

Keywords

contraception long-acting reversible contraception (LARC)permanent contraception postpartum COVID-19

Equitable access to contraception is an essential component of public health and warrants ongoing evaluation and planning by government and public health entities. Unintended pregnancies and short interpregnancy intervals (the time from the end of one pregnancy to the start of the next; hereafter, “short-interval pregnancies”) are associated with poor health outcomes for postpartum people and infants.^1-4 Timely initiation of effective postpartum contraception is an important tool to reduce the rates of unintended and short-interval pregnancies and improve maternal and infant health outcomes.^2,5 Furthermore, barriers to accessing preferred methods of contraception impede reproductive autonomy; therefore, it is imperative that regulatory agencies and health care systems prioritize access to contraceptives.⁶ Postpartum people should have access to the full range of contraceptive methods to meet their reproductive health care needs, including highly effective methods such as long-acting reversible contraception (LARC) and female permanent contraception (eg, tubal ligation). LARC has been shown to substantially reduce unintended and short-interval pregnancies.^2,7 Thus, the American College of Obstetricians and Gynecologists (ACOG) recommends that immediate postpartum LARC be discussed during prenatal contraceptive counseling and available to all patients.^2,8,9 Female permanent contraception is one of the most effective forms of contraception, and ACOG recommends that postpartum people have the opportunity to access these contraceptive procedures, which ACOG designates as nonelective.¹⁰

Following national recommendations aimed at reducing the spread of COVID-19, most states issued executive orders in March 2020 that included the postponement of elective and nonurgent medical procedures and outpatient visits, as well as a stay-at-home order and health insurance mandates to cover telehealth visits. In April 2020, frameworks for determining which services could be delayed were released by the Centers for Medicare & Medicaid Services; however, guidance on reproductive health care services was not included.^11,12 Concern that pandemic countermeasures may have negatively affected access to reproductive health services, including designation of reproductive health procedures as elective or nonurgent, was expressed by the reproductive health community early in the pandemic.^13-16 Indeed, a national survey conducted by the Guttmacher Institute during April 30–May 6, 2020, found that 1 in 3 women had difficulty accessing reproductive health care or contraception because of the COVID-19 pandemic.¹⁶

Findings vary on the extent to which provision of postpartum contraception was disrupted by the COVID-19 pandemic. Decreases in provision of female permanent contraception and/or LARC at the start of the pandemic have been noted in data from commercial health plans from Michigan, in a nationwide sample of multipayer claims, and at a teaching hospital in Illinois.^17-19 In addition, a shift toward immediate postpartum LARC insertions and away from outpatient LARC insertions was reported by a single academic medical center in Washington, DC.²⁰ However, to our knowledge, no study has yet examined population-level state data or the provision of postpartum contraception in a largely rural state such as Maine. Rural populations may be more vulnerable than urban populations to disruptions in reproductive health care service because of barriers in accessing care, such as decreased availability of obstetric and family planning clinicians, increased travel time to hospitals and appointments, and higher rates of poverty and use of public health insurance.²¹

The objective of our analysis was to estimate changes in provision of postpartum contraception at the start of the COVID-19 pandemic in Maine by using an interrupted time-series analysis design with 6- and 12-month follow-up periods. We anticipated that changes might have occurred in contraception provision after implementation of emergency measures in Maine, which may have introduced barriers to reproductive health care.

Methods

Data

We used the Maine Health Data Organization’s All Payer Claims Database for this analysis. In addition to all-payer claims for hospital inpatient and outpatient visits, these data include claims paid for Maine residents by public payers and private insurers for private physician visits, clinic visits, and prescription claims, as required by state statute and rules.^22,23 We analyzed claims data from patients aged 16-55 years who delivered from October 2015 (the start of International Classification of Diseases, Tenth Revision, Clinical Modification codes in the United States) through March 2021 (the latest month of complete data available at the time of the analysis). We identified deliveries using a code list for live births and stillbirths published by the Alliance for Innovation on Maternal Health²⁴ that we augmented by adding delivery-related Current Procedural Terminology (CPT) codes. We excluded stillbirth deliveries from our analysis because people experiencing stillbirth may have unique postpartum contraception needs and there is currently no recommended minimum interpregnancy interval following a stillbirth.²⁵

We determined delivery dates by using an algorithm developed by our team, which preferentially used service dates of delivery-related CPT codes from professional claims rather than those from delivery-related facility claims, which capture hospitalization service dates, not necessarily delivery dates. We identified approximately 90% of delivery dates by using CPT code service dates, and we identified the remaining 10% by using service dates for other delivery-related claims. We characterized health insurance type by using the payer for the delivery-related claims and identified cesarean section delivery by using diagnosis and procedure codes. We determined rural versus urban residency according to the zip code at the time of delivery by using the US Department of Agriculture rural–urban commuting area codes, which classify census tracts based on population density, urbanization, and daily commuting patterns.²⁶ We categorized these codes into rural (large rural, small rural, and isolated rural) and urban (core metropolitan, small metropolitan) per a classification scheme developed by the New England Rural Health Association.^26,27

The institutional review board at the University of Southern Maine determined this study to be exempt from human subjects review because it used secondary data through a data use agreement.

Outcomes

Our primary outcomes were rates of provision of postpartum contraception within 3 and 60 days of delivery. We measured provision within 3 days to capture immediate postpartum provision prior to hospital discharge and within 60 days to capture provision from delivery through the first postpartum visit. We based these measures on a contraceptive care performance measure published and maintained by the US Office of Population Affairs and used by the Centers for Medicare & Medicaid Services.²⁸ This measure categorizes contraceptive methods as the following: LARC (intrauterine devices, implants), female permanent contraception (bilateral tubal ligation or salpingectomy, also known as female sterilization), and moderately effective contraceptive methods (injectables, oral pills, patch, ring, or diaphragms).

Statistical Analysis

Interrupted time-series model

Using an interrupted time-series analysis design,^29,30 we estimated changes in rates of provision of postpartum contraception after the start of the COVID-19 pandemic. We performed 2 sets of analyses: a 6-month analysis to estimate the immediate effects at the start of the pandemic and a 12-month analysis to estimate longer-term effects (eFigure1 in Supplemental Material). A civil state of emergency went into place in Maine in mid-March 2020, which included guidance to postpone elective procedures and medical appointments; a stay-at-home directive was issued on March 31, 2020.³¹ April 2020 was the first full month after these countermeasures were in place; therefore, our postpandemic cohorts were April–September 2020 for the 6-month analysis and April 2020–March 2021 for the 12-month analysis. We used the prepandemic cohort, October 2015–March 2020, as the reference group for both analyses.

We aggregated data by delivery month, with the number of women with live births as the denominator and the number of women with each contraception provision type as the numerator. We included diaphragm as a moderately effective method to be consistent with measures from the Office of Population Affairs. We counted multiple live births (eg, twins) to the same woman once. We used Poisson regression models, offset for the number of women with live births and with robust SEs to correct for autocorrelation, to calculate rate ratios (RRs) and 95% CIs for the level change (ie, jump) at the start of the pandemic as well as the slope change (ie, change in trends) after the start of the pandemic. We calculated smoothed rates for April 2020 (the first month after the start of the pandemic) based on observed data in the postpandemic cohort and compared those rates with predicted rates for April 2020 based on prepandemic data, assuming that no pandemic had occurred. The level-change RR corresponds to the smoothed rates for April 2020 divided by the predicted rates for April 2020.

We examined seasonal trends in postpartum provision of contraception and found no abrupt changes through visual inspection. We also reviewed Maine Medicaid’s contraception policies³² to ensure that no changes coincided with the start of the COVID-19 pandemic.

Model fit and sensitivity analysis

We fit linear and quadratic models and assessed goodness of fit using the quasi-likelihood under independence model criterion. Because linear models were generally a better fit to the data, we used these models for our analysis. For a sensitivity analysis, we repeated the analysis excluding the month of March 2020 to assess whether findings changed when we treated this month as a transition month.

Subgroup and post hoc analysis

We performed a subgroup analysis by rural versus urban residency at the time of delivery. Maine has the highest percentage of residents living in a rural area in the United States,³³ and unique barriers to access in care are experienced by rural communities, which may increase the risk of adverse maternal and infant health outcomes related to unintended and short-interval pregnancies.^25,34

After reviewing preliminary results, we conducted a post hoc analysis to identify changes in permanent contraception by payer among patients who delivered by cesarean section. We conducted this analysis because we found that most 3-day permanent contraception procedures, in the pre- and postpandemic cohorts, occurred among patients who delivered via cesarean section (82%). We used SAS version 9.4 (SAS Institute) for analysis.

Results

We included 45 916 deliveries in the study: 38 219 in the pre–COVID-19 cohort (October 2015–March 2020) and 7697 in the 12-month post–COVID-19 cohort (April 2020–March 2021). Characteristics of the 2 cohorts were similar (Table 1).

Table 1.

Characteristics of deliveries before and after the start of the COVID-19 pandemic, Maine^a

Characteristic	Before COVID-19 pandemic (October 2015–March 2020)	After start of COVID-19 pandemic (April 2020–March 2021)
Total deliveries, no.	38 219	7697
Mean age, y	29.1	29.6
Health insurance type, no. (%)
Medicaid	21 740 (56.9)	4429 (57.5)
Commercial	16 427 (43.0)	3256 (42.3)
Cesarean section, no. (%)	11 195 (29.3)	2342 (30.4)
Residence type,^b no. (%)
Rural	24 425 (63.9)	4977 (64.7)
Urban	13 618 (35.6)	2703 (35.1)
Missing	0	17 (0.2)

Data source: Maine Health Data Organization’s All Payer Claims Database.²²

Rural residence type was based on zip code–level rural–urban commuting area codes and categorization scheme from the New England Rural Health Association. Rural included large, small, and isolated rural; urban included core metropolitan and small metropolitan.^26,27

During October 2015–March 2021, the average provision rates of LARC, female permanent contraception, and moderately effective methods within 3 days were 9.5, 65.4, and 15.5 per 1000 deliveries, respectively; corresponding provision rates within 60 days were 153.2, 74.7, and 224.4 per 1000 deliveries. Use of individual contraceptive methods in the pre- and postpandemic cohorts can be found in eTable 1 in Supplemental Material. Diaphragm use accounted for <0.1% of contraceptive methods before and after the start of the pandemic.

6-Month Analysis: April–September 2020

We found immediate increases in the rate of provision of LARC within 3 days (RR = 1.89; 95% CI, 1.76-2.02), and the rate of provision of LARC within 60 days was stable (RR = 0.95; 95% CI, 0.93-0.97) (Figure 1, Table 2). The rate of provision of moderately effective contraception within 3 days increased immediately after the start of the COVID-19 pandemic (RR = 1.51; 95% CI, 1.33-1.72), and that within 60 days was stable (RR = 1.08; 95% CI, 1.05-1.11) (eFigure 2 in Supplemental Material, Table 2). The rate of provision of permanent contraception within 3 days (RR = 0.70; 95% CI, 0.63-0.78) and 60 days (RR = 0.71; 95% CI, 0.63-0.80) decreased immediately after the start of the pandemic (Figure 2, Table 2). Slope changes (change in trends) after the start of the pandemic were generally slight, except for provision of LARC within 3 days, which changed from an increasing slope before the start of the pandemic to a decreasing slope after the start of the pandemic (eTable 2 in Supplemental Material).

Figure 1.

Monthly rates of long-acting reversible contraception (LARC) provision within 3 days of delivery before and after the start of the COVID-19 pandemic, Maine, October 2015–September 2020. Shading indicates 95% confidence bands for smoothed rates before and after the pandemic. Dashed vertical line indicates the start of the pandemic in March 2020. Data source: Maine Health Data Organization’s All Payer Claims Database.²²

Table 2.

Changes in rates (per 1000 deliveries) of LARC, female permanent contraception, and moderately effective contraception within 3 and 60 days of delivery after the start of the COVID-19 pandemic, Maine^a

	6-month analysis			12-month analysis
Type of contraception	Level change, RR (95% CI)	Predicted rate for April 2020^b	Smoothed rate for April 2020^c	Level change, RR (95% CI)	Predicted rate for April 2020^b	Smoothed rate for April 2020^c
LARC
Within 3 d of delivery	1.89 (1.76-2.02)	10.9	20.5	1.57 (1.31-1.87)	11.6	18.2
Within 60 d of delivery	0.95 (0.93-0.97)	161.1	153.1	1.04 (1.01-1.08)	156.4	163.3
Permanent contraception
Within 3 d of delivery	0.70 (0.63-0.78)	71.2	49.9	0.90 (0.81-0.99)	66.1	59.1
Within 60 d of delivery	0.71 (0.63-0.80)	80.8	57.2	0.91 (0.80-1.03)	74.8	67.9
Moderately effective^d
Within 3 d of delivery	1.51 (1.33-1.72)	15.1	22.8	1.60 (1.40-1.83)	14.8	23.7
Within 60 d of delivery	1.08 (1.05-1.11)	218.5	235.3	1.02 (0.99-1.05)	222.0	226.4

Abbreviations: LARC, long-acting reversible contraception; RR, rate ratio.

Data source: Maine Health Data Organization’s All Payer Claims Database.²²

Assuming no pandemic.

Based on observed data.

Moderately effective methods include injectables, pill, patch, ring, and diaphragm.

Figure 2.

Monthly rates of female permanent contraception provision within 3 days of delivery before and after the start of the COVID-19 pandemic, Maine, October 2015–September 2020. Shading indicates 95% confidence bands for smoothed rates before and after the pandemic. Dashed vertical line indicates the start of the pandemic in March 2020. Data source: Maine Health Data Organization’s All Payer Claims Database.²²

12-Month Analysis: April 2020–March 2021

When compared with the results of the 6-month analysis, level- and slope-change RRs in the 12-month analysis were attenuated (Table 2; eTable 2 in Supplemental Material; eFigures 3-5 in Supplemental Material).

Rural–Urban Subgroup Analysis

In our 6-month analysis by rural versus urban residence, we found that rates of provision of 3-day LARC and 3-day moderately effective contraception were higher for rural residents than for urban residents and that changes in rates of provision of 3-day permanent contraception were similar (Table 3; eTable 3 in Supplemental Material). In the 12-month analysis, estimates for provision of LARC within 3 days were similar between rural and urban residents, but provision of moderately effective contraception within 3 days was higher among rural than among urban residents.

Table 3.

	6-month analysis			12-month analysis
Outcome by subgroup	Level change, RR (95% CI)	Predicted rate for April 2020^b	Smoothed rate for April 2020^c	Level change, RR (95% CI)	Predicted rate for April 2020^b	Smoothed rate for April 2020^c
LARC
Within 3 d of delivery
Urban	1.62 (1.41-1.86)	18.3	29.7	1.58 (1.28-1.93)	18.4	29.0
Rural	2.34 (2.11-2.60)	6.7	15.6	1.51 (1.21-1.88)	7.9	11.9
Within 60 d of delivery
Urban	0.93 (0.89-0.98)	178.8	167.1	1.08 (0.98-1.19)	171.2	185.0
Rural	0.96 (0.94-0.98)	151.1	144.6	1.02 (0.99-1.06)	147.7	151.1
Female permanent contraception
Within 3 d of delivery
Urban	0.76 (0.65-0.90)	49.7	38.0	0.93 (0.76-1.12)	47.1	43.7
Rural	0.69 (0.63-0.76)	82.7	57.2	0.89 (0.82-0.97)	76.4	68.1
Within 60 d of delivery
Urban	0.81 (0.67-0.97)	55.1	44.4	0.95 (0.72-1.24)	52.4	49.7
Rural	0.69 (0.62-0.76)	94.6	65.1	0.90 (0.83-0.99)	86.9	78.5
Moderately effective method^d
Within 3 d of delivery
Urban	1.37 (1.19-1.58)	18.9	25.8	1.37 (1.12-1.67)	19.2	26.2
Rural	1.64 (1.42-1.88)	13.0	21.2	1.76 (1.55-2.00)	12.6	22.2
Within 60 d of delivery
Urban	1.19 (1.13-1.24)	192.6	228.8	1.07 (0.99-1.16)	198.0	212.7
Rural	1.02 (1.00-1.05)	233.6	239.2	0.99 (0.96-1.03)	235.9	234.2

Abbreviations: LARC, long-acting reversible contraception; RR, rate ratio.

Data source: Maine Health Data Organization’s All Payer Claims Database.²²

Assuming no pandemic.

Based on observed data.

Moderately effective methods include injectables, pill, patch, ring, and diaphragm.

Post Hoc and Sensitivity Analysis

In our post hoc analysis of changes in rates of permanent contraception among cesarean sections by payer type, we found a decrease after the start of the pandemic for deliveries that Medicaid paid for (RR = 0.60; 95% CI, 0.51-0.71) but not for deliveries that commercial health insurance paid for (RR = 1.08; 95% CI, 0.97-1.21) (eFigure 6 in Supplemental Material). Our sensitivity analysis excluding March 2020 resulted in RR estimates for level change and slope change within ±10% of the primary analysis.

Discussion

After the start of the COVID-19 pandemic in Maine, we found abrupt increases in the provision of LARC and moderately effective contraception within 3 days of delivery and decreases in the provision of female permanent contraception. These findings were fairly robust to our use of 6- and 12-month analyses, which captured the immediate and longer-term effects of the pandemic on postpartum contraception provision.

The increase in rates of provision of LARC within 3 days of delivery may reflect patient and/or clinician anticipation of delayed in-person postpartum visits, with immediate postpartum LARC selected as an expedited alternative. In addition, given that LARC provision rates within 60 days postpartum did not change after the start of the pandemic, the increased rates found for that within 3 days may represent a shift from outpatient to inpatient provision. Similarly, while we found an increase in provision rates of moderately effective contraception within 3 days, we found no change within 60 days postpartum. This increase could represent an attempt to bridge women with moderately effective contraception while awaiting a more effective method to be provided at a later visit, or it may reflect concerns about delays of in-person postpartum visits; it could also represent patients’ increased preference for these types of contraceptive methods during the start of the pandemic. As with LARC, the findings of a null provision rate for moderately effective contraception within 60 days may indicate a shift from outpatient to inpatient provision.

The decrease in permanent contraception within 3 days could be due to policies in place in Maine at the start of the COVID-19 pandemic, which did not designate permanent contraception procedures as nonelective and could have resulted in canceled or postponed procedures. Because this decrease appeared to be primarily among people with Medicaid, it could also be due to the pandemic disrupting patients’ ability to complete the Consent for Sterilization form at least 30 days before the procedure date, which is required for Medicaid but not for commercial health insurance.¹⁴ The decrease in provision rates within 60 days for permanent contraception were the same as the rates within 3 days because tubal ligations are unlikely to be scheduled between hospital discharge and 60 days postpartum, which is a time of physical recovery from the delivery.

We found little difference in rates of provision of contraceptive method based on rurality of maternal residence zip code; this finding implies that adaptations to routine care were seen across the health care spectrum and may have similarly affected postpartum rural and urban residents in Maine.

Our findings were generally attenuated in the 12-month analysis, which suggests that the changes in provision of contraception at the start of the pandemic were transient when examined with a longer view. Nonetheless, concerns remain about barriers to accessing permanent contraception at the start of the pandemic. Reproductive health care, including abortion, contraception, and fertility services, have historically been designated as elective and nonurgent, and this designation was reflected in several state policies and guidelines during the pandemic, most notably for abortion care.^13-15,35 However, most states, including Maine, provided no guidance for which procedures and services fell under the designation of elective or nonessential services. Without clear guidance from federal agencies or state governments, these determinations were left to individual health systems and facilities.

Strengths and Limitations

This analysis had several limitations. First, claims data do not allow for assessment of patient preferences or reasons for use or nonuse of certain contraceptive methods. Second, these data do not include sociodemographic information, such as race and ethnicity and educational attainment,²² which are associated with type of contraceptive method provision but were unlikely to change substantially during the study period and bias our results. Third, the data that we used also excluded patients without health insurance, who are less likely than insured patients to attend visits for postpartum contraceptive and outpatient health care; however, these patients represent a small fraction of pregnant people (ie, 7% in a 2016 national study³⁶). Fourth, the data that we used omitted claims related to substance use disorder, in response to a regulation from the Substance Abuse and Mental Health Services Administration.²² This redaction removes a subset of the postpartum population that may have unique contraceptive needs, and it is unknown how omission of these observations affected our study’s estimates. Approximately 35 per 1000 women delivering in Maine in 2018 had opioid use disorder,³⁷ so at least 3.5% of deliveries were likely missing from our analysis. Fifth, we could have used a more granular time scale or alternative time scale for our analysis (eg, midmonth to midmonth, as the emergency measures in Maine began in mid-March 2020). The greatest strength of our study was our use of a comprehensive claims database, which captured data on contraception provision at inpatient and outpatient encounters, in private physicians’ offices and clinics, and through pharmacy claims.

Conclusions

Contraception provision is essential and time sensitive, and barriers to its access result in loss of personal and family rights related to reproductive choice.¹⁶ Additionally, poor health outcomes as a consequence of unintended and short-interval pregnancies can have long-standing effects for individuals, families, and communities.¹ Our analysis suggests that disruptions in permanent contraception occurred because of the COVID-19 pandemic and the emergency measures put in place to decrease virus transmission. Further research is warranted to examine potential disparities in access to permanent contraception by payer source. In the future, federal agencies could consider including guidance on which reproductive health care services are essential and designating postpartum permanent contraception as a nonelective procedure to help reduce barriers to access during public health emergencies.

Supplemental Material

sj-docx-1-phr-10.1177_00333549231170198 – Supplemental material for Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine

Supplemental material, sj-docx-1-phr-10.1177_00333549231170198 for Provision of Postpartum Contraception Before and After the Start of the COVID-19 Pandemic in Maine by Catherine Gelsinger, Kristin Palmsten, Heather S. Lipkind, Mariah Pfeiffer, Christina Ackerman-Banks, Jennifer A. Hutcheon and Katherine A. Ahrens in Public Health Reports

Footnotes

Acknowledgements

The authors thank the Maine Health Data Organization, which is responsible for the State of Maine’s All Payer Claims Database. We used the Maine Health Data Organization’s All Payer Claims Database for this analysis as authorized under data request 2021040501.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: K.P. has research contracts with AbbVie, GSK, and Sanofi that are unrelated to the current study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this article was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award R15HD101793. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iD

Catherine Gelsinger, RN

Supplemental Material

Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th Edition.

Data Sharing

Because of the sensitive nature of the data collected for this study, requests to access the dataset from qualified researchers trained in human subjects confidentiality protocols may be sent to Maine Health Data Organization at

References

Finer

Zolna

MR.

Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med. 2016;374(9):843-852. doi:10.1056/NEJMsa1506575

Eisenberg

Negassa

Levi

Associations between immediate postpartum long-acting reversible contraception and short interpregnancy intervals. Contraception. 2020;102(6):409-413. doi:10.1016/j.contraception.2020.08.016

Nelson

Darney

Ahrens

, et al. Associations of unintended pregnancy with maternal and infant health outcomes: a systematic review and meta-analysis. JAMA. 2022;328(17):1714-1729. doi:10.1001/jama.2022.19097

Ahrens

Nelson

Stidd

Moskosky

Hutcheon

JA.

Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: an updated systematic review. Paediatr Perinat Epidemiol. 2019;33(1):O25-O47. doi:10.1111/ppe.12503

Tepper

Jamieson

Marchbanks

PA.

Update to CDC’s US medical eligibility criteria for contraceptive use, 2010: revised recommendations for the use of contraceptive methods during the postpartum period. MMWR Morb Mortal Wkly Rep. 2011;60(26):878-883.

Potter

Stevenson

Coleman-Minahan

, et al. Challenging unintended pregnancy as an indicator of reproductive autonomy. Contraception. 2019;100(1):1-4. doi:10.1016/j.contraception.2019.02.005

Parks

Peipert

JF.

Eliminating health disparities in unintended pregnancy with long-acting reversible contraception (LARC). Am J Obstet Gynecol. 2016;214(6):681-688. doi:10.1016/j.ajog.2016.02.017

Harney

Dude

Haider

Factors associated with short interpregnancy interval in women who plan postpartum LARC: a retrospective study. Contraception. 2017;95(3):245-250. doi:10.1016/j.contraception.2016.08.012

Gifford

McDuffie

Rashid

, et al. Postpartum contraception method type and risk of a short interpregnancy interval in a state Medicaid population. Contraception. 2021;104(3):284-288. doi:10.1016/j.contraception.2021.05.006

10.

American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women. Access to postpartum sterilization: ACOG Committee opinion, number 827. Obstet Gynecol. 2021;137(6):e169-e176. doi:10.1097/AOG.0000000000004381

11.

Centers for Medicare & Medicaid Services. CMS adult elective surgery and procedures recommendations. Updated April 7, 2020. Accessed March 19, 2022. https://www.cms.gov/files/document/covid-elective-surgery-recommendations.pdf

12.

Centers for Medicare & Medicaid Services. Non-emergent, elective medical services, and treatment recommendations. 2020. Updated April 7, 2020. Accessed March 19, 2022. https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf

13.

Robinson

Moulder

Zerden

Miller

Zite

NB.

Preserving and advocating for essential care for women during the coronavirus disease 2019 pandemic. Am J Obstet Gynecol. 2020;223(2):219-220.e1. doi:10.1016/j.ajog.2020.05.022

14.

Evans

Qasba

Shah Arora

COVID-19 highlights the policy barriers and complexities of postpartum sterilization. Contraception. 2021;103(1):3-5. doi:10.1016/j.contraception.2020.10.006

15.

Gross

Harrington

Sufrin

Faden

RR.

Rethinking “elective” procedures for women’s reproduction during COVID-19. Hastings Cent Rep. 2020;50(3):40-43. doi:10.1002/hast.1130

16.

Lindberg

VandeVusse

Mueller

Kirstein

. Early impacts of the COVID-19 pandemic: findings from the 2020 Guttmacher Survey of Reproductive Health Experiences. 2020. Accessed February 28, 2023. https://www.guttmacher.org/report/early-impacts-covid-19-pandemic-findings-2020-guttmacher-survey-reproductive-health

17.

Steenland

Geiger

Chen

, et al. Declines in contraceptive visits in the United States during the COVID-19 pandemic. Contraception. 2021;104(6):593-599. doi:10.1016/j.contraception.2021.08.003

18.

Becker

Moniz

Tipirneni

Dalton

Ayanian

JZ.

Utilization of women’s preventive health services during the COVID-19 pandemic. JAMA Health Forum. 2021;2(7):e211408. doi:10.1001/jamahealthforum.2021.1408

19.

Sakowicz

Matovina

Imeroni

, et al. The association between the COVID-19 pandemic and postpartum care provision. Am J Obstet Gynecol MFM. 2021;3(6):100460. doi:10.1016/j.ajogmf.2021.100460

20.

Das

KJH

Fuerst

Brown

Lesko

. Use of postpartum contraception during coronavirus disease 2019 (COVID-19): a retrospective cohort study. Int J Gynaecol Obstet. 2021;155(1):64-71. doi:10.1002/ijgo.13805

21.

ACOG Committee opinion no. 586: health disparities in rural women. Obstet Gynecol. 2014;123(2, pt 1):384-388. doi:10.1097/01.AOG.0000443278.06393.d6

22.

Maine Health Data Organization. Claims—the All Payer Claims Database (APCD). 2013. Accessed December 20, 2022. https://mhdo.maine.gov/claims.htm

23.

Maine Health Data Organization. Rule 90-590, chapter 243: uniform reporting system for health care claims data sets. Accessed December 20, 2022. https://mhdo.maine.gov/_finalStatutesRules/Chapter%20243%20Claims%20Data_211115.pdf

24.

Heslin

Owens

Karaca

Barrett

Moore

Elixhauser

Trends in opioid-related inpatient stays shifted after the US transitioned to ICD-10-CM diagnosis coding in 2015. Med Care. 2017;55(11):918-923. doi:10.1097/MLR.0000000000000805

25.

World Health Organization. Report of a WHO technical consultation on birth spacing: Geneva, Switzerland 13-15 June 2005. 2007. Accessed February 28, 2023. https://www.who.int/publications/i/item/WHO-RHR-07.1

26.

US Department of Agriculture, Economic Research Service. Rural–urban commuting area codes. August 17, 2020. Accessed March 19, 2022. https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes.aspx

27.

New England Rural Health Roundtable. Rural data for action: a comparative analysis of health data for the New England region. 2014. Accessed May 5, 2022. https://nerha.memberclicks.net/assets/docs/RHRT_DataBook_2014_FINAL.pdf

28.

US Department of Health and Human Services, Office of Population Affairs. Measure CCP: contraceptive care—postpartum women ages 15-44. 2020. Accessed December 14, 2022. https://opa.hhs.gov/sites/default/files/2021-08/2020-measure-specifications-CCP.pdf

29.

Bernal

Soumerai

Gasparrini

A methodological framework for model selection in interrupted time series studies. J Clin Epidemiol. 2018;103:82-91. doi:10.1016/j.jclinepi.2018.05.026

30.

Linden

Conducting interrupted time-series analysis for single- and multiple-group comparisons. Stata J. 2015;15(2):480-500. doi:10.1177/1536867x1501500208

31.

State of Maine, Office of the Governor. COVID-19 response: response timeline. Accessed December 14, 2022. https://www.maine.gov/covid19/timeline

32.

Department of Health and Human Services. MaineCare Benefits Manual: 10-144 Ch 101. Ch II § 45, hospital services. Accessed December 20, 2022. https://www.maine.gov/sos/cec/rules/10/144/ch101/c2s045.docx

33.

US Census Bureau. Growth in urban population outpaces rest of nation, Census Bureau reports. News release. March 26, 2012. Accessed December 20, 2022. https://www.census.gov/newsroom/releases/archives/2010_census/cb12-50.html

34.

US Department of Health and Human Services. Healthy People 2020 objectives: family planning. Accessed February 24, 2023. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C13-FP.pdf

35.

Weigel

Salganicoff

Ranji

. Potential impacts of delaying “non-essential” reproductive health care. Issue brief. Kaiser Family Foundation; 2020. Accessed February 24, 2023. https://www.kff.org/womens-health-policy/issue-brief/potential-impacts-of-delaying-non-essential-reproductive-health-care/#:~:text=We%20know%20that%20forgoing%20prenatal,15%25%20of%20couples%20with%20infertility

36.

Daw

Sommers

BD.

The Affordable Care Act and access to care for reproductive-aged and pregnant women in the United States, 2010-2016. Am J Public Health. 2019;109(4):565-571. doi:10.2105/ajph.2018.304928

37.

Gabrielson

SMB

Carwile

O’Connor

Ahrens

. Maternal opioid use disorder at delivery hospitalization in a rural state: Maine, 2009-2018. Public Health. 2020;181:171-179. doi:10.1016/j.puhe.2019.12.014

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