Understanding delivery type as a mediator in the relationship between insurance type and permanent contraception fulfillment: a mixed-methods multi-site study.

INTRODUCTION: Many patients who desire postpartum permanent contraception cannot obtain it, with barriers linked to insurance type - particularly Medicaid's 30-day consent policy - and delivery type (cesarean vs. vaginal). This study uses a mixed-methods approach to examine whether delivery type mediates the relationship between insurance type and permanent contraception fulfillment. METHODS: We conducted a concurrent mixed-methods analysis of data collected from three US hospitals. We analyzed quantitative data from 2,794 patients (2018-2019) using mediation analysis to assess the indirect effect of insurance type on contraception fulfillment via delivery type. We also thematically analyzed qualitative data from semi-structured interviews with 67 patients and 54 obstetrician-gynecologists (2022-2023) to explore how delivery type influences contraceptive decision-making and service provision. RESULTS: Mediation analysis showed a significant indirect effect of insurance type on contraception fulfillment through delivery type (average causal mediation effect: -0.06; 95% confidence interval [CI]: -0.10, -0.04). Medicaid patients had higher odds of delivering vaginally (odds ratio [OR]:1.78; 95% CI: 1.44, 2.21), and vaginal delivery was strongly associated with reduced fulfillment (OR: 0.05; 95% CI: 0.04, 0.07). Qualitative findings reinforced these results. Patients and providers described how Medicaid's consent policy delayed access, while cesarean delivery made permanent contraception easier. Providers more often discussed permanent contraception with patients already undergoing a cesarean delivery, and patients who delivered vaginally faced logistical challenges with follow-up care. DISCUSSION: Delivery type is an important mediator in the relationship between insurance type and postpartum permanent contraception fulfillment. Addressing policy restrictions, provider counseling disparities, and institutional constraints is critical to ensuring equitable contraceptive access.