This study was a secondary analysis of our previous cross-sectional study conducted among postpartum women at a tertiary hospital in Bangkok, Thailand. The original study aimed to describe the differences in contraceptive choices during the COVID-19 pandemic compared to the pre-pandemic era. Postpartum women who delivered from January 1 to June 30, 2019 (pre-pandemic period) and January 1 to June 30, 2020 (pandemic period) were included (4,450 postpartum women in total: 2,277 from pre-pandemic period, and 2,168 from pandemic period). The results of the original study have been published elsewhere. Briefly, we found that there were no differences in demographic or obstetric characteristics, or postpartum contraceptive choices immediately after delivery and at six weeks postpartum between the pre-pandemic and pandemic groups. Women who delivered at less than 22 weeks of gestation (the limit of viability at our hospital) or had incomplete medical records were excluded. Demographic and obstetric data were collected from the medical records. The demographic information included age, ethnicity, marital status, address, healthcare coverage, and underlying medical conditions. The obstetric information included gravidity, parity, gestational age at delivery, postpartum complications, and neonatal outcomes. Data on whether and which method of contraception was initiated immediately after delivery were collected from the medical records.
Female sterilization is covered by healthcare plans to varying degrees. Universal coverage, government officers, and hospital officers were covered for all costs involved in the hospital stay, including female sterilization. Patients covered by social security were paid a lump sum of 15,000 baht (1 USD = 31.8–31.9 baht during the study period) to cover delivery and newborn costs, including costs of contraception; the patients could retain whatever remained from the lump sum along with paid time off. A small portion of patients who opted to deliver in a hospital outside their network paid out-of-pocket for hospital fees. Hospital fees at our target hospital were 1,300–4,000 baht (35-108 USD) for vaginal delivery (an additional 8,000 baht (217 USD) for postpartum sterilization), and 11,300 baht (300 USD) for cesarean delivery (with an additional 1,100 baht (30 USD) for sterilization along with cesarean delivery). Generally, accommodation, including meals for one day of hospital stay, costs 900–1,800 baht (24-48 USD). To determine whether healthcare coverage affects the decision to be sterilized, we divided the analytic set into two groups: women who were covered for sterilization (universal coverage, hospital employees, and government officers) and women who were not fully reimbursed for sterilization (social security and out-of-pocket payment).
At our hospital, women receive contraceptive counseling during the third trimester of antenatal care and the immediate postpartum period. Patients may state their desire for postpartum sterilization during antenatal care, delivery, or hospital stay. Sterilization is offered to women in their third (or higher) pregnancy and to patients with high-risk pregnancies. Sterilization intentions were documented in all women who had obstetric indications for elective cesarean delivery at antenatal care, and if desired, sterilization was performed during the cesarean delivery. Patients who were not indicated for elective cesarean delivery could express sterilization intention during antenatal care, as documented in the medical records. Among those who delivered via emergency cesarean section, patients were asked for sterilization intention prior to the operation, and sterilization was performed in the same operation if desired. Patients were discharged on the third postoperative day; the length of hospital stay was similar between patients who delivered via cesarean section and those who underwent simultaneous sterilization and cesarean delivery. Those who delivered vaginally were provided counseling on contraceptive options by trained nurses, and if desired, sterilization was performed prior to discharge. Patients who delivered vaginally were discharged on the second day post-delivery; those who were sterilized were discharged similarly, except those who delivered on Fridays, Saturdays, and Sundays, who had to wait until Monday for sterilization. Under these circumstances, patients could be discharged the following day. There were no mandatory waiting times between the expression of intent and the sterilization operations. Spousal consent was not required, but the women were encouraged to inform their spouses about their decisions. The operating room and anesthesiologist were available on Mondays through Fridays for sterilization. Trained physicians performed sterilization under spinal anesthesia.
The contraceptive methods available at our hospital were as follows: combined oral contraceptive pills (COC), progestin-only pills, progestin-only injections, levonorgestrel and etonogestrel contraceptive implants, copper intrauterine device (Cu-IUD), levonorgestrel intrauterine system (LNG-IUS), male and female sterilization, and male condoms. Long-acting reversible contraception includes levonorgestrel or etonogestrel implants, Cu-IUDs, and LNG-IUS, and is free of charge for adolescents and all women in Bangkok, where our hospital is located. Other methods of contraception were not covered by healthcare plans.
Data were collected and managed using Research Electronic Data Capture (REDCap), a secure web-based software platform hosted at King Chulalongkorn Memorial Hospital10. Statistical analyses were performed using STATA version 17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.). Quantitative variables were characterized by mean values with standard deviations (SD), and qualitative variables were characterized by the number and percentage of participants in each category. Multivariable logistic regression was used to determine the association between the different types of health coverage and postpartum female sterilization.