Analysis of Contraceptive Use among Immigrant Women following Expansion of Medicaid Coverage for Postpartum Care

Importance: Access to postpartum care is restricted for low-income women who are recent or undocumented immigrants enrolled in Emergency Medicaid. Objective: To examine the association of a policy extending postpartum coverage to Emergency Medicaid recipients with attendance at postpartum visits and use of postpartum contraception. Design, Setting, and Participants: This cohort study linked Medicaid claims and birth certificate data from 2010 to 2019 to examine changes in postpartum care coverage on postpartum care and contraception use. A difference-in-difference design was used to compare the rollout of postpartum coverage in Oregon with a comparison state, South Carolina, which did not cover postpartum care. The study used 2 distinct assumptions to conduct the analyses: first, preintervention differences in postpartum visit attendance and contraceptive use would have remained constant if the policy expanding coverage had not been passed (parallel trends assumption), and second, differences in preintervention trends would have continued without the policy change (differential trend assumption). Data analysis was performed from September 2020 to October 2021. Exposures: Medicaid coverage of postpartum care. Main Outcomes and Measures: Attendance at postpartum visits and postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery. Results: The study population consisted of 27667 live births among 23971 women (mean [SD] age, 29.4 [6.0] years) enrolled in Emergency Medicaid. The majority of all births were to multiparous women (21289 women [76.9%]; standardized mean difference [SMD] = 0.08) and were delivered vaginally (20042 births [72.4%]; SMD = 0.03) and at term (25502 births [92.2%]; SMD = 0.01). Following Oregon's expansion of postpartum coverage to women in Emergency Medicaid, there was a large and significant increase in postpartum care visits and contraceptive use. Assuming parallel trends, postpartum care attendance increased by 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P <.001) following the policy change. Under the differential trends assumption, postpartum visits increased by 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P <.001). Postpartum contraception use increased similarly. Under the parallel trends assumption, postpartum contraception within 60 days increased by 33.2 percentage points (95% CI, 31.1-35.4 percentage points; P <.001). Assuming differential trends, postpartum contraception increased by 28.2 percentage points (95% CI, 25.8-30.6 percentage points; P <.001). Conclusions and Relevance: These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use..