Abstract
“Successful initiation and continuation of postpartum contraception can decrease unintended pregnancy rates and improve maternal and child health outcomes.”
The postpartum period can be an ideal time to help a woman initiate contraception. Initiation of contraception in the immediate postpartum period is an important public health intervention. Shortened birth intervals (births spaced less than 2 years apart) are associated with significant maternal [1] and perinatal [2] morbidity. However, 33.1% of pregnancies in the USA are conceived within 18 months of a previous birth [3]. Successful initiation and continuation of postpartum contraception can decrease unintended pregnancy rates and improve maternal and child health outcomes.
During pregnancy and the postpartum period, many women have access to medical care who otherwise would not. The inpatient admission for childbirth is a convenient opportunity for providers and patients to navigate contraceptive options together, particularly when the discussion has been raised in the antepartum period. There are pressing reasons to consider immediate postpartum contraception. After delivery, return to fertility can be rapid, with resumption of ovulation averaging 45 days, and occurring as early as 3 weeks postpartum in nonlactating women [4]. Delaying contraceptive initiation until several weeks postpartum places women at risk for unintended pregnancy.
A range of contraceptive methods may be appropriate for women postpartum, and discussion should begin with the most effective options. Long-acting reversible contraceptive (LARC) methods, including the etonogestrel contraceptive implant and intrauterine devices, offer contraceptive efficacy and ease of user compliance. They combine cost–effectiveness with the benefit of being the most effective methods available. Immediate postpartum LARC placement has emerged as a safe and evidence-based practice. The US Medical Eligibility Criteria for Contraceptive Use supports immediate postplacental IUD insertion following cesarean section and vaginal delivery, and contraceptive implant insertion prior to hospital discharge, in lactating and nonlactating women [5]. Guidelines from the American College of Obstetricians and Gynecologists support the postpartum period as a particularly favorable time to initiate LARC [6]. And, from a public health standpoint, LARC has been found to be an important intervention to help women achieve optimal birth spacing and decrease rates of unplanned pregnancy [7–9].
Despite evidence supporting provision of immediate postpartum LARC, provider misinformation persists. A recent survey of 3000 members of the American Congress of Obstetricians and Gynecologists fellows found that only 11% of providers recognize the safety of postplacental IUD insertions [10]. Further, institutional and health policy barriers often limit immediate postpartum LARC provision. This contributes to wide variation in postpartum LARC use and availability [11]. Recognizing the potential public health impact of immediate postpartum LARC provision, several states have changed their funding practices to improve reimbursement for LARC initiation prior to hospital discharge [12]. Supporting this, despite the high initial cost associated with LARC devices, the cost–effectiveness of the contraceptive implant to prevent unintended repeat pregnancies in high-risk adolescent populations has been established [13].
Contraceptive implant
The etonogestrel implant is a single rod made of ethylene vinyl acetate that measures 4 cm by 2 mm. The implant contains 68 mg of etonogestrel that is released at a rate of 60 μg daily and is metabolized to the active metabolite desogestrel. The contraceptive implant is effective for 3 years and the primary mechanism of action is to prevent ovulation.
Evidence for immediate postpartum contraceptive implant insertion
The safety of the contraceptive implant placed within 48 h postpartum has been established. Postpartum insertion is not associated with adverse maternal clinical outcomes, and does not impact breastfeeding or infant weight gain [14]. There are no obstetric-related contraindications for contraceptive implant use [5]. The primary side effect experienced by contraceptive implant users is irregular uterine bleeding, which contributes to early discontinuation for up to 14% of women who select this method [15]. While this remains a clinical challenge, initiation in the immediate postpartum period has not been associated with increased removal rates secondary to vaginal bleeding patterns [16].
IUDs
Two types of IUDs are available in the USA and many other countries – the copper (CuT380A) IUD and the levonorgestrel (LNG) IUDs. Their primary mechanism of action is to prevent fertilization [17]. The Cu-IUD is approved for 10 years of use, and LNG-IUD for 3 or 5 years. Benefits of IUDs include their high contraceptive effectiveness and favorable side effect profile. The noncontraceptive benefit of decreased menstrual bleeding with the LNG-IUD may contributes to its high patient satisfaction [18]. Puerperal sepsis, endomyometritis, presence of uterine anomaly and unresolved postpartum hemorrhage are all absolute contraindications to postplacental IUD insertion [5].
Evidence for postplacental IUD insertion
The safety of postplacental IUD insertion has been established for both vaginal and cesarean delivery and is supported by the US Medical Eligibility Criteria for Contraceptive Use [5]. Postplacental IUD insertion is not associated with adverse maternal outcomes. One study found that the postpartum LNG-IUD was associated with a shorter duration and less exclusive breastfeeding compared with interval insertion [19], but there is no direct evidence of adverse effects on breast milk or the breastfeeding infant.
Studies of postpartum IUDs indicate that insertion within 10 min of delivery of the placenta has the lowest expulsion rates compared with insertion intervals up to 72 h after delivery, though both have higher rates than interval insertion [20]. Risk for expulsion is lower in the setting of cesarean section when compared with vaginal deliveries. While expulsion rates may be higher than seen with interval insertion, they may be acceptable in settings where women are less likely to present for care unrelated to pregnancy; this option decreases logistic barriers associated with interval IUD insertion. Continuation of the IUD at 1 year appears similar for postplacental and interval insertion [19,21]. Complication rates for the Cu-IUD are not increased based on postpartum insertion timing, and no studies to date provide comparative data on complication rates for the LNG-IUD [5]. Given the recognized risk for uterine perforation in lactating women associated with IUD insertion in the weeks following delivery [22], immediate postplacental insertion may be a preferable option compared with later postpartum insertion.
Postpartum LARC & patient choice
While there are many benefits to initiating postpartum LARC, we must honor patient autonomy in contraceptive decision making [23]. Successful contraceptive counseling helps each woman best meet her own needs regarding fertility, contraceptive and non-contraeptive benefits, and risks, but the informed decision must be hers. Given the option, many women may prefer a long-acting method [24]. However, contraception is ineffective upon discontinuation, and immediate postpartum LARC uptake will be successful only if women who choose these methods elect to continue use. Improved provider knowledge, evidence-based health policy changes, and emphasis on informed patient choice will help to maximize the potential for immediate postpartum LARC to make a difference for women.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.