Department of Obstetrics and Gynecology, the Department of Epidemiology, Gillings School of Global Public Health, and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; the Department of Obstetrics and Gynecology and the Center for Health Care Research and Policy, Population Health Research Institute, MetroHealth Medical System, Cleveland, Ohio; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; the Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, California; and the Department of Sociology, Steve Hicks School of Social Work, University of Texas at Austin, Austin, Texas.
Obstet Gynecol. 2023 May 1;141(5):918-925. doi: 10.1097/AOG.0000000000005130. Epub 2023 Apr 5.
To evaluate the association between Medicaid insurance and fulfillment of postpartum permanent contraception requests.
We conducted a retrospective cohort study of 43,915 patients across four study sites in four states, of whom 3,013 (7.1%) had a documented contraceptive plan of permanent contraception at the time of postpartum discharge and either Medicaid insurance or private insurance. Our primary outcome was permanent contraception fulfillment before hospital discharge; we compared individuals with private insurance with individuals with Medicaid insurance. Secondary outcomes were permanent contraception fulfillment within 42 and 365 days of delivery, as well as the rate of subsequent pregnancy after nonfulfillment. Bivariable and multivariable logistic regression analyses were used.
Patients with Medicaid insurance (1,096/2,076, 52.8%), compared with those with private insurance (663/937, 70.8%), were less likely to receive desired permanent contraception before hospital discharge (P≤.001). After adjustment for age, parity, weeks of gestation, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index, private insurance status was associated with higher odds of fulfillment at discharge (adjusted odds ratio [aOR] 1.48, 95% CI 1.17-1.87) and 42 days (aOR 1.43, 95% CI 1.13-1.80) and 365 days (aOR 1.36, 95% CI 1.08-1.71) postpartum. Of the 980 patients with Medicaid insurance who did not receive postpartum permanent contraception, 42.2% had valid Medicaid sterilization consent forms at the time of delivery.
Differences in fulfillment rates of postpartum permanent contraception are observable between patients with Medicaid insurance and patients with private insurance after adjustment for clinical and demographic factors. The disparities associated with the federally mandated Medicaid sterilization consent form and waiting period necessitate policy reassessment to promote reproductive autonomy and to ensure equity.
评估医疗补助保险与满足产后永久性避孕需求之间的关联。
我们对四个州的四个研究地点的 43915 名患者进行了回顾性队列研究，其中 3013 名（7.1%）在产后出院时记录了永久性避孕计划，并且有医疗补助保险或私人保险。我们的主要结局是在出院前实现永久性避孕；我们将有私人保险的个体与有医疗补助保险的个体进行了比较。次要结局是在分娩后 42 天和 365 天内实现永久性避孕的情况，以及未满足需求后的后续妊娠率。使用了双变量和多变量逻辑回归分析。
与有私人保险的患者（663/937，70.8%）相比，有医疗补助保险的患者（1096/2076，52.8%）更不可能在出院前获得所需的永久性避孕（P≤.001）。在校正年龄、产次、孕周、分娩方式、产前保健充分性、种族、民族、婚姻状况和体重指数后，私人保险状况与更高的出院时满足率（调整后的优势比[aOR]1.48，95%可信区间[CI]1.17-1.87）和 42 天（aOR 1.43，95%CI 1.13-1.80）以及 365 天（aOR 1.36，95%CI 1.08-1.71）后满足率相关。在 980 名未接受产后永久性避孕的有医疗补助保险的患者中，有 42.2%在分娩时持有有效的医疗补助绝育同意书。
在调整了临床和人口统计学因素后，有医疗补助保险的患者和有私人保险的患者在满足产后永久性避孕的比例上存在差异。与联邦授权的医疗补助绝育同意书和等待期相关的差异需要重新评估政策，以促进生殖自主权并确保公平。
