Findings from this study highlight that, among a national sample of people with a recent live birth from 20 jurisdictions, postpartum LARC use increased overall from 2015 to 2018 and the use of no contraceptive method also increased. Much of the increase in nonuse was seen from 2015 to 2016. We found that respondents without insurance at the time of the survey had lower odds of using permanent, LARC, and SARC methods in 2018 compared with those with private insurance, and that use of contraception among this group did not shift significantly from 2015 to 2018. Additionally, in 2018 respondents in rural settings had greater odds of using contraception across all method categories compared with no method.

Barriers that can impact postpartum contraceptive care may occur both immediately postpartum and throughout the postpartum period. Barriers to postpartum contraceptive care may include insufficient providers trained on insertion and removal of methods, disparate provider counseling, lack of same-day availability of methods, barriers related to insurance coverage, and the level of provider reimbursement for LARC insertion immediately postpartum (Aiken et al., 2015; Fuerst & George, 2020; Kroelinger et al., 2017; Oduyebo et al., 2019; Power to Decide, n.d.; Rodriguez et al., 2014). Multiple large-scale programs and research studies that focused on reducing barriers to contraceptive access, such as the Contraceptive CHOICE Project (McNicholas et al., 2014) and the Zika Contraception Access Network (Lathrop et al., 2018; 2020), have reported that when women were provided patient-centered contraceptive counseling and choice among the full range of contraceptive methods at low or no cost and on the same day, coupled with enhanced provider training, use of contraception increased, particularly LARC methods (Biggs et al., 2015; Lathrop, et al., 2018; 2020; Peipert et al., 2014; Ricketts et al., 2014; Secura et al., 2010). These large-scale studies underscore that, when multicomponent strategies to improve access to contraception are implemented, women of reproductive age are more likely to use highly effective contraceptive methods. Given our findings that postpartum contraceptive nonuse increased over time, and the known benefits of postpartum contraception, implementing strategies demonstrated to address barriers to accessing contraceptive care can increase use. Implementation strategies can consider geographically specific context such as rurality and variation in state-level policies.

Although changes in contraceptive coverage that followed implementation of the ACA and expansion of Medicaid decreased out-of-pocket costs for many insured individuals (Becker & Polsky, 2015; Bearak et al., 2016; Finer et al., 2014; Sonfield et al., 2015) and have been associated with increased use of contraceptives (Carlin et al., 2016; Chuang, et al., 2015; Law et al., 2016; Snyder et al., 2018), differences in uptake by insurance status remain. Our results highlight that in 2018, postpartum people without insurance at the time of the survey had lower odds of using permanent methods, LARC, and SARC compared with those with private insurance coverage, but there were no significant differences in use of those method categories between respondents with public and private insurance. Additionally, there were no significant changes in contraceptive method use from 2015 to 2018 among people without postpartum insurance. Many group and individual health insurance plans, including Medicaid plans for those newly eligible by the ACA’s Medicaid expansion, are required to cover recommended preventive services for women of reproductive age without cost sharing when provided in network, including contraceptive counseling, initiation of contraceptive use, and follow-up care such as the management, evaluation, and removal or discontinuation of the contraceptive method (Health Resources & Services Administration, 2020; Centers for Medicare & Medicaid Services, n.d. c). Moreover, previous research has reported that women with private and public health insurance are more likely than those without insurance to report using contraception, including LARC and SARC methods (Kavanaugh et al., 2019). Our findings, in concert with existing literature that demonstrates those without insurance coverage have lower rates of contraception use (Culwell & Feinglass, 2007; Nearns, 2009), and that lack of insurance acts as a barrier to preventive services (Sudano & Baker, 2003), suggest postpartum people without insurance coverage may face unique barriers to accessing effective contraception.

In 2018, respondents in rural areas had greater odds of using all categories of contraception compared with those in urban areas. Our study adds to the mixed findings of U.S.-based studies on contraceptive method use. Although some studies have similarly found women in rural areas were more likely to use effective contraception (Damm et al., 2013; Travers et al., 2017), others have found those in urban settings more likely to use effective contraception (Geske et al., 2016), and still others found no significant difference between rural and urban settings (Snyder et al., 2018). However, most previous studies have used smaller, single-state samples (Bruce et al., 2020; Damm et al., 2013; Geske et al., 2016; Travers et al., 2017). The findings from this multistate, multiyear sample suggest that, across method types, postpartum people in rural settings are more likely to use effective contraception, and that urban nonuse increased from 2015 to 2018. This difference was especially pronounced in the use of permanent contraception; even after adjusting for insurance type, age, race/ethnicity, and parity, respondents from rural settings had more than twice the odds of using permanent methods. Furthermore, despite increased LARC use in urban settings from 2015 to 2018, those in rural areas still had 1.31 times the odds of using LARC in 2018 compared with those in urban areas. Noted barriers to health care access and service use in rural areas include a dearth of local health care personnel and longer travel distances to care (National Center for Chronic Disease Prevention and Health Promotion, 2019). Although we found differences in urban versus rural populations, the data are limited in their ability to explain what is driving these differences. There may be differences in the facilitators and barriers to accessing contraceptive options for people in urban areas compared with rural areas. For example, one analysis found that women in rural settings with more limited access to health care services may be more inclined to select longer term or permanent methods to avoid the need for more regular follow-up with a health care provider (Travers et al., 2017). Recent national and state-level efforts to increase access to contraception included initiatives to improve access to contraception in rural areas (Kroelinger, et al., 2017; The Association of State and Territorial Health Officials, 2015; 2016). To ensure that postpartum people have access to and counseling on a full range of methods regardless of their geographic setting, future studies can investigate what is driving differences in contraceptive use between rural and urban populations.

The postpartum period is an important time for birthing people to have equitable access to a full range of contraceptive methods (Rodriguez et al., 2014). LARC use up to 6 months postpartum has been reported as higher than LARC use in general, which other studies suggest may be due in part to the motivation to avoid rapid repeat or unintended pregnancy and the increased availability of services and insurance coverage during pregnancy and the postpartum period (Cohen et al., 2016; de Bocanegra et al., 2014). However, Medicaid eligibility in the postpartum period varies by state. For instance, states have different eligibility thresholds for low-income adults, and states that have adopted Medicaid expansion have higher income eligibility thresholds than states that have not (Biggs et al., 2015; Brooks et al., 2020; Haley & Johnston, 2021). Additionally, although federal law requires that states extend pregnancy-related Medicaid eligibility through 60 days postpartum for women with incomes up to 138% of the federal poverty level, the decision to continue coverage beyond those 60 days varies by state (Social Security Act, § 1902; Centers for Medicare & Medicaid Services, 2020). For example, in April, 2021, Illinois became the first state to expand postpartum Medicaid coverage for up to 1 year after childbirth (U.S. Department of Health and Human Services, 2021). Some states have used the section 1115 waiver process for such extensions, and others are using an option available under the American Rescue Plan for five years to offer 12 months of postpartum Medicaid coverage (American Rescue Plan Act of 2021, 2021; Ranji et al., 2021). Alternatively, states can apply to the Centers for Medicare and Medicaid Services for a waiver to extend coverage for 12 months postpartum under section 1115 of the Social Security Act as a strategy for increasing access to contraception and other preventive health services (Centers for Medicare and Medicaid Services, 2021). States may also explore strategies of revising payment methodologies for immediate postpartum LARC reimbursement (Wachino, 2016a; 2016b). Additionally, states may consider supporting provider training to increase capacity to effectively deliver quality family planning services and offer a full range of methods (Edwards & O’Neill, 2018; Ricketts et al., 2014). Such efforts align with clinical guidance for pregnant and postpartum patients to receive patient-centered counseling about the full range of postpartum contraceptive options in a context that supports informed decision making and increases same-day access when desired (American College of Obstetricians Gynecologists Committee on Obstetric Practice, 2016; Curtis, Jatlaoui, et al., 2016; Curtis, Tepper, et al., 2016; Gavin et al., 2014).

Although our study provides a recent multistate analysis on variation in postpartum contraceptive method use, we note some key limitations. PRAMS relies on self-reported data, which may lead to social desirability bias in the reporting of sexual behaviors, such as contraceptive use. Although this may lead to slightly inaccurate reporting of overall contraceptive use, research suggests that social desirability bias is not significantly associated with demographic characteristics (Crutzen & Göritz, 2010), and therefore should not have significantly altered our overall results. The insurance variable was based on insurance at the time of the survey; however, respondents are surveyed between 2 and 6 months postpartum and some respondents had a different insurance status immediately postpartum than they had at the time the survey was taken, which could have impacted their use of contraceptive methods. Rurality was defined using a binary variable at the county level, which does not capture granularity in geographic environments. Permanent contraception was not disaggregated between male and female sterilization, so this study does not demonstrate which of the two is driving use of permanent contraception. This analysis only included states that participate in PRAMS and met the minimum sampling requirement for all years from 2015 to 2018. Although states were included from regions across the United States, the results may not be generalizable to states not included in this analysis, particularly those that did not meet PRAMS response rate thresholds. It is also possible that bias may have resulted from excluding participants with missing data on outcomes of interest. Furthermore, these aggregate multistate findings may mask state-specific patterns. Additional state-level research could inform state and local programmatic and policy decisions. Because this is a cross-sectional study, causality cannot be inferred.

In 2018, among people in the postpartum period 2–6 months after giving birth, those without insurance coverage had lower odds of using effective contraceptive methods, which may be attributable to barriers to accessing contraceptive services for people without insurance. Birthing people living in rural areas had greater odds of using all methods types; further research is needed to better explain differences by urbanicity and higher nonuse in urban areas. From 2015 to 2018, postpartum use of LARC increased from 17.8% to 18.7% and use of no contraceptive method increased from 13.7% to 15.8%. This finding suggests that, although the use of highly effective methods may be increasing, contraceptive nonuse postpartum is also increasing and has implications for short interpregnancy intervals.