Learning Objectives:After participating in this continuing education activity, the provider should be better able to:

1. Outline patient counseling regarding the risks associated with short interpregnancy intervals.

2. Explain risks and benefits of placement of immediate postpartum long-acting reversible contraception (LARC).

3. Identify contraindications to immediate postpartum LARC placement.

4. Describe the impact of reimbursement for immediate postpartum LARC.

Long-acting reversible contraception (LARC) devices, including intrauterine devices (IUDs) and the contraceptive implant, are highly effective, reversible, and have few contraindications.1 In the United States, nearly half of all pregnancies are unintended. In recent decades the use of LARC has contributed to a significant decrease in such pregnancies, especially among adolescents and young adult women.1-4 Short interpregnancy intervals, most commonly defined as the interval between delivery and a subsequent pregnancy of less than 18 months, are associated with significant maternal and fetal morbidity and mortality.5-7 Approximately one-third of pregnancies in the United States occur within short interpregnancy intervals.8,9 These pregnancies are often unintended, highlighting the potential value of LARC as a preventative measure.8

Traditionally, discussion of birth control has been deferred until the 6-week postpartum visit. However, evidence demonstrates that many women initiate intercourse before this visit, with estimates ranging from 47% to 57% of women having intercourse by 6 weeks postpartum.10,11 Additionally, many women do not follow up for their postpartum visit at all. Although the rates vary across different populations, it has been estimated that nationally, up to 60% of women with Medicaid do not attend a postpartum visit.12 Women who do not follow up postpartum are more likely to be young and black and also have depression, a disability and/or substance use disorder, and have other children at home.12

There are significant barriers to initiation of LARC among women who attend a postpartum visit more than 6 weeks after delivery. These include loss of insurance and subsequent inability to pay, need for multiple visits, and provider variation in offering this method.13 Given these barriers, it is not surprising that a significant number of women who intend to use LARC postpartum ultimately do not do so. In one study of low-income, Medicaid-insured women, one-third who planned to use LARC postpartum ultimately did not do so. Inability to attend a postpartum visit was the most frequently cited barrier.14

The immediate postpartum period (ie, the time right after delivery) allows for initiation of effective contraception prior to reinitiation of intercourse among a population of women who may not follow up postpartum or may otherwise face significant barriers to LARC placement.

Recent attention has been given to providing LARC methods immediately postpartum (IPP) as a means of further reducing unintended pregnancy and abortion rates. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics endorse IPP-LARC placement.1,15-17 The US Medical Eligibility Criteria for Contraceptive Use considers it safe with a category 1 (use in any circumstance, no restriction for use) or category 2 (generally use the method, advantages generally outweigh risks).13 As such, obstetrical providers should be able to counsel their patients appropriately regarding the risks of short interpregnancy intervals, and the contraindications, risks, and benefits of IPP-LARC insertion, all of which will be reviewed in this article.

LARC Devices and IPP Definitions

Currently, there are 5 IUDs approved by the FDA, 4 containing levonorgestrel (LNG) IUDs and 1 copper IUD.1 The only approved implant in the United States is the etonogestrel implant.1,13 The various LARC devices, their content, and approved duration of use are summarized in Table 1.1,13

Table 1. LARC Devices Content and FDA Duration of Use

In considering postpartum LARC device insertion, definitions vary by method and specific timing. The etonogestrel implant can be inserted at any time during a woman's postpartum hospital stay.13 With IUD insertion, several intervals have been studied: postplacental (insertion within 10 minutes of placental delivery), immediate (insertion during postpartum admission), and interval (anytime during the menstrual cycle not in relation to the end of a pregnancy). According to ACOG, best practice for IPP IUD insertion is within 10 minutes of placental delivery. Insertion after a vaginal or cesarean delivery is described specifically in an ACOG Committee Opinion.13 The IUD can be inserted either manually or with a ring forceps after a vaginal delivery. The IUD strings are cut to 10 cm, the wings of the IUD are grasped, such as with the ring forceps, and the IUD is passed through the cervix and placed at the fundus. Ultrasonographic confirmation of placement may be used. After cesarean delivery, the IUD is inserted after removal of the placenta and after the uterus has become hemostatic. After initiating closure of the uterine incision, the IUD is placed at the fundus with the inserter, manually, or with ring forceps, and the string gently placed manually or with ring forceps into the cervix.

Short Interpregnancy Interval Definition and Risks

A short interpregnancy interval is most commonly defined as the interval between delivery and a subsequent pregnancy of less than 18 months. Such pregnancies are common in the United States, with 30% to 35% of all pregnancies meeting this criterion. Approximately 70% of pregnancies conceived with an interpregnancy interval of less than 12 months are unintended.5-9 Short interpregnancy intervals have been associated with fetal and maternal complications including, but not limited to, increased risk of low birth weight, preterm birth, small-for-gestational-age infants, increased neonatal intensive care unit admissions, postpartum bleeding, and uterine rupture with history cesarean delivery.5,6 Notably, there is an increased risk of mortality for infants born with an interpregnancy interval of less than 6 months and 6 to 12 months when compared with infants born to mothers who had an interval between pregnancies of greater than 18 months.6

Impact of LARC on Short Interpregnancy Intervals

Use of LARC during the postpartum period significantly reduces the rate of short interpregnancy intervals.7,8,10 Data from a large retrospective study of over 370,000 women across the United States enrolled in the Military Healthcare System demonstrated that the prevalence of short interpregnancy intervals was 6% among those who initiated LARC at their postpartum visit versus 21% among those who used combined hormonal methods of contraception.7 The 2006-2010 National Survey of Family Growth reported that 0.5% of women using LARC became pregnant in the 18 months after an index birth compared with 12.6% of those using hormonal contraception.8

IP- LARC insertion has been shown to be effective in preventing short interpregnancy intervals. In a study analyzing the impact of IPP etonogestrel implant insertion on rapid repeat pregnancy among individuals in an adolescent prenatal-postnatal program (ages 13-24 years), the pregnancy rate at 12 months was 18.6% among non-LARC users compared with 2.6% of LARC users. Notably, 47% of these adolescents and young adult women resumed sexual intercourse before 6 weeks postpartum, and 21 of the 38 observed pregnancies that occurred were within 6 months postpartum.10

South Carolina, the first state to expand Medicaid coverage for IPP-LARC in 2012, recently examined the effect of coverage on both LARC utilization and short interpregnancy intervals. With coverage, IPP-LARC utilization increased. Additionally, prior to expansion of Medicaid, short interpregnancy intervals among adolescents were increasing at a steady rate and this rate effectively flattened with IPP-LARC coverage.18

IPP IUD Insertion

Contraindications

According to ACOG, contraindications to IPP IUD insertion include intrauterine infection, postpartum hemorrhage, and puerperal sepsis in addition to the accepted contraindications associated with interval insertions.13 In the face of these peripartum complications, insertion is often delayed until the 6 week postpartum visit, although there is no clearly specified interval.13 There is no increased risk of postpartum infection with IPP IUD placement.13

Risks

When inserted in the immediate postplacental interval, the risk for expulsion ranges from 3% to 27% (compared with approximately 3%-10% for interval insertions).19-24 Although the majority of IPP IUDs are placed postplacentally, there have been several studies evaluating immediate insertion (insertion greater than 10 minutes after delivery of placenta prior to discharge from the hospital) and risk of expulsion. These studies have demonstrated an increased risk of expulsion with rates of up to 38%.25 Thus, most IUDs are placed within 10 minutes of placental delivery as recommended by ACOG.

Expulsion rates vary by delivery mode and IUD type (Table 2). In multiple meta-analyses, the expulsion rate has been shown to be higher after vaginal as compared with cesarean delivery, with a risk ratio as high as 4.5.26 The type of IUD chosen also appears to have an impact on expulsion rates.24 A recent meta-analysis demonstrated that the risk of expulsion with IPP placement of an LNG-IUD was 1.9 times that of expulsion with IPP of a copper IUD.26 No insertion method has been found to be associated with significantly lower rates of expulsion.24

Table 2. Intrauterine Device Rates of Expulsion, Perforation, and Continuation by Timing of Insertion

Perforation rates are lower with postplacental insertion (0%-0.2%) compared with interval placements (0.03%-0.26%).19-24 When placed at the 6-week postpartum visit, the risk of expulsion returns to that of baseline, but risk of perforation is increased up to 2%.19-24

Continuation Rates

In many populations, continuation rates are higher IPP placement of an IUD as compared with IUD placement 6 or more weeks postpartum. A recent study of women aged 18 to 45 years with both public and private insurance undergoing cesarean delivery demonstrated that postplacental insertion was associated with a 6-month continuation rate of 83% compared with a 64% continuation rate observed in those whose IUD was placed 6 weeks postpartum.27

IPP Implant Insertion

Contraindications

The etonogestrel implant can be inserted at any time during a woman's postpartum stay. There are no contraindications specific to postpartum etonogestrel insertion outside of standard contraindications. There are also no specific risks to insertion in the postpartum period, with the exception of theoretical concerns surrounding effects on lactation discussed later.13

Continuation Rates

Similar to the IUD, continuation rates of the etonogestrel implant when placed IPP are comparatively higher than when placed outside of the postpartum setting. One study demonstrated a 66% 3-year continuation rate when placed IPP. Among adolescents, continuation rates at 12 months have been up to 78% irrespective of recent pregnancy28 compared with 86% continuation at 12 months when placed IPP.10

Effects of IPP Hormonal LARC on Breastfeeding

There are theoretical concerns that both the LNG-IUD and etonogestrel implant negatively impact breastfeeding, given the association between progesterone withdrawal and onset of lactation. These concerns have not been substantiated in the literature, although the data are limited by small sample size. A single small secondary analysis compared 27 women who initiated the LNG-IUD IPP to 21 women who had delayed placement and demonstrated no difference in patient-reported breastfeeding at 6 weeks, 8 weeks, and 3 months postpartum. Women in the delayed group did continue breastfeeding beyond 6 months more often, and were more likely to breastfeed exclusively.29 More recently, a larger noninferiority study compared 132 women with IPP LNG-IUD placement to 127 with delayed LNG-IUD placement. This study demonstrated IPP LNG-IUD placement to be noninferior with regard to time to lactogenesis and breastfeeding continuation at 8 weeks.30

In a study comparing 12 women who underwent IPP insertion of an etonogestrel implant to 12 women using no contraception, there were no significant differences in measures of lactation including breast milk volume and exclusive breastfeeding at 6 weeks postpartum.31 Given the available evidence, ACOG recommends that women should be informed of a theoretical risk, but the data have not demonstrated a negative impact of progestin-containing methods on breastfeeding.

Cost-effectiveness and Coverage for IPP-LARC

IPP insertion of both the IUD and contraceptive implant has been found to be cost-effective in multiple analyses.32,33 Despite the high upfront cost, IPP implant insertion was associated with a significant cost savings by 12 months; this savings increased at 24 and 36 months.32 Cost-benefit analyses support placement of IPP-LARC due to the effect of reducing unintended pregnancies taking into account both the risk of IUD expulsions and method discontinuation.33 Given the significant cost-benefit of IPP-LARC placement, funding through Medicaid state agencies has increased over recent years. Recent estimates demonstrate that approximately half of the Medicaid state agencies provide coverage for IPP-LARC insertion.34

Conclusion

LARC devices are highly effective contraceptive methods with few contraindications that have been associated with decreased rates of unintended pregnancy and short interpregnancy intervals.1,7,8,10,13 IPP-LARC insertion is associated with decreased short interpregnancy intervals and short-interval births. Insertion of IPP-LARC has an overall favorable risk-benefit ratio, with cost savings to the health care system.7,8,10,19-24,27,35 Obstetrician-gynecologists should counsel their patients regarding the risks of short interpregnancy intervals and the risks and benefits of IPP-LARC insertion. They should be familiar with the contraindications to IPP use, and actively pursue strategies that reduce barriers to use.

Practice Pearls

* Short interpregnancy intervals are defined as the time from delivery to the subsequent pregnancy of less than 18 months.

* Approximately one-third of pregnancies in the United States occur within short interpregnancy intervals.

* Short interpregnancy intervals are associated with maternal and fetal complications including increased infant mortality. Up to 70% of these pregnancies are unintended.

* LARC significantly reduces the risk of a short interpregnancy interval occurrence.

* Approximately half of the postpartum women have intercourse prior to their 6-week postpartum visit.

* Immediate postplacental IUD insertion is associated with an increased risk of expulsion compared with interval insertion.

* IUD insertion at the 6-week postpartum visit is associated with an increased risk of perforation.

* Contraindications to postplacental IUD placement are intrauterine infection, postpartum hemorrhage, and puerperal sepsis.

* There is no clear evidence that the LNG-IUD or etonogestrel implant negatively affects breastfeeding.

* Despite the increased risk of expulsion with postplacental insertion, cost-benefit analysis still demonstrates a benefit when considering the cost of unintended pregnancy.

* Covering cost of IPP-LARC through Medicaid expansion or other funding sources increases utilization.

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