Home Visiting to Prevent Unintended Pregnancies

Cristian I. Meghea, PhD: Cristian I. Meghea, PhDLee Anne Roman, MSN, PhD: Lee Anne Roman, MSN, PhDMore than two-fifths of U.S. pregnancies are unintended (ie, wanted later or unwanted), a rate significantly higher than most other developed countries. For non-Hispanic Black individuals, the unintended pregnancy rate is twice that of non-Hispanic White persons, and unintended pregnancies are five times more frequent among birthing individuals with low incomes compared with more affluent people.1 Medicaid covers close to half of all U.S. pregnancies and births. As a result, approximately two-thirds of the unintended pregnancies and births are covered by public insurance programs.2 At the same time, publicly funded family planning services, including Medicaid, help birthing individuals avoid unwanted or mistimed pregnancies and plan pregnancies they do want. Approaches to reducing subsequent pregnancies that are unintended include include the timely provision of effective contraceptives to birthing people during delivery hospitalization, if appropriate, or during an early postpartum visit. A key component to successful contraception is prenatal and postnatal contraceptive counseling, including conversations about reproductive goals (eg, reproductive life planning), health risks of short interpregnancy intervals, and contraceptive preferences. Just as critical for contraception success are follow-up strategies once contraception is initiated, especially monitoring side effects and switching methods if necessary. Yet, comprehensive contraception support can be challenging for both health care professionals and patients given limited time in clinical encounters and underutilization of postpartum care.3 Many individuals with Medicaid insurance have access to enhanced prenatal and postnatal care home visiting. Home visiting programs, in the context of a longer-term supportive relationship, can provide contraceptive counseling and follow-up and address barriers to care, especially given competing priorities and newborn care in the postpartum period. An article in this month's issue of Obstetrics & Gynecology (see page 3) evaluated the effect of an intensive nurse home visiting program on postpartum contraception and birth spacing among individuals eligible for Medicaid insurance with a first pregnancy in South Carolina.4 A randomized controlled trial was conducted of the Nurse-Family Partnership (NFP), an established, intensive nurse home visiting program that provides prenatal and postpartum home visits through 2 years after childbirth. The trial population included individuals eligible for Medicaid insurance with a first pregnancy at less than 28 weeks of gestation. There were no statistically significant effects of the NFP intervention on the likelihood of a subsequent birth within 21 months of the study index birth or on any of the study's eight secondary outcomes related to birth spacing and postpartum contraceptive use. The intervention significantly improved the use of a patch, ring, an implant at 12 months postpartum, which were exploratory outcomes. Although several prior NFP studies have demonstrated improvements in birth spacing, we concur with the authors that the lack of intervention effects on this study's primary and secondary outcomes was likely influenced by a series of statewide, population-level efforts to reduce unintended pregnancy before and during the time the study was conducted. Policy, advocacy, and public health efforts increased long-acting reversible contraceptive availability and use as a first-line contraception method. By 2016, South Carolina had the sixth highest rate of effective contraception use among individuals enrolled in Medicaid in the United States, at greater than 40% within 60 days postpartum. Patient timing preferences, including birth spacing, also could have played a role. More than two-thirds of the pregnant participants in both the intervention and control arms wanted to have more children in the future, and up to 20% of the participants received a patch, ring, or contraceptive implant by 12 months postpartum. It is then possible that many of the repeat births within 21 months of the index birth, the main study outcome, were intended pregnancies. For all of these reasons, there may have been little room left for improvement by the NFP. For Black participants, at higher risk of unintended pregnancy and the majority of the study sample (55%), contraception counseling also is influenced by a historical context of mistrust, reproductive mistreatment, and coercion. Discussions about reproductive goals and contraception are deeply personal, are tied to broader life goals, and are best conducted in the context of an established, trusting relationship.5 Perhaps race matters in such conversations. In an NFP qualitative study, Black birthing people did perceive racially concordant visitors more favorably by fostering trust and communication.6 However, recruiting Black nurses for NFP, or any other home visiting program, is difficult.7 For example, only 12% of South Carolina's nurses are Black.8 To address the gap on race, ethnicity, and language–concordant health care professionals for home visiting, we are testing a model that partners Black and Latine community health workers with licensed nurses and social workers in the context of a state-wide home visiting program to reach and serve high-risk Black and Latine clients.9 Important for contraception care, this team approach doubled the share of participants receiving postpartum visits to 43% by 3 weeks postpartum and increased it to 86% by 60 days, compared with usual care.9 Yet, little is known about how race-concordant home visiting influences contraception care and unintended pregnancy. Work remains to be done to ensure reproductive autonomy, reduce unintended pregnancy, and address equity while grounding contraceptive care in the principles of person-centeredness, especially for those individuals facing disparities. Interpregnancy contraceptive care, even with methods initiated before delivery discharge, is intrinsically linked to postpartum care. Why, in the context of well-established supportive relationships in home visiting, has it been difficult to effect the underutilization of postpartum and contraception care? A recently published person-centered contraceptive care framework calls for a multilevel approach (eg, historical and social context, health care, access, community, family) and specifically calls for synergies across the continuum of care to meet individuals' contraceptive needs.10 Thus, the opportunity for improvement in postpartum contraceptive care may lie in breaking down current siloed care in clinical and home visiting settings to create more clinical–community care connections. Integrated care, with authentic community engagement and expanded contraceptive access, counseling, and follow-up while meeting individuals' contraceptive preferences, is needed to ensure equitable contraceptive care.