Health Insurance Status and Contraceptive Utilization Among Women Who Had an Unintended Pregnancy in Massachusetts: Healthcare Reform Implications

BACKGROUND: Unintended pregnancy is associated with poor birth outcomes and suboptimal prenatal behaviors.  It represents about half of all births nationally and costs taxpayers more than $9 billion annually. Lower income women are more likely to experience unintended pregnancy. Massachusetts (MA) implemented healthcare reform and Medicaid expansion in 2007, which increased coverage of contraceptives. Understanding how contraceptive utilization among women who experienced an unintended pregnancy varies by health insurance type can inform strategies for improving family planning services and reducing unintended pregnancy.

METHODS: MA Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2007-2010 (n = 1,732) were analyzed to examine the association between utilizing contraception at conception and pre-pregnancy health insurance (Medicaid vs. private insurance) among women who experienced an unintended pregnancy resulting in a live birth. Unintended pregnancy was defined as wanting to be pregnant later or not at all. Stratified multivariate logistic regression controlling for maternal race/Hispanic ethnicity was conducted to measure the association by year (2007/2008 vs. 2009/2010). Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated. Analysis was limited to unintended pregnancies resulting in live birth, and did not include women who had a miscarriage or abortion.

RESULTS: During 2007-2008, Medicaid recipients had a higher prevalence of unintended pregnancy compared to privately insured women (50.8% vs. 23.7%). Similar results were found during 2009-2010 (49.8% vs. 22.8%, respectively). Among women who experienced an unintended pregnancy during 2007-2008, Medicaid recipients did not differ significantly in contraception utilization from those with private insurance (aPR 0.91, 95%CI 0.73-1.14), controlling for maternal race/Hispanic ethnicity. In contrast, during 2009-2010, Medicaid recipients were more likely than those with private insurance to utilize contraception (aPR 1.25, 95%CI 1.03-1.52).

CONCLUSIONS: At the implementation of healthcare reform in MA during 2007-2008, women with Medicaid and private insurances who had unintended pregnancies did not differ in contraception utilization at conception. In contrast, among women who had an unintended pregnancy, women on Medicaid in 2009-2010 were more likely to utilize contraception compared to privately insured women. These findings suggest that healthcare coverage may have improved women’s access to contraception among the Medicaid population. However, even with increased contraceptive utilization, the Medicaid population had a higher prevalence of unintended pregnancy, suggesting that more research is needed to examine contraceptive adherence and effectiveness. PRAMS data on contraceptive type were not collected until 2012. Though unavailable for this analysis, the effectiveness of contraceptives used by women with unintended pregnancies can be assessed going forward.