New moms choose sterilization over IUDs: What can reverse trend?

Include reversible options when permanent procedures discussed

While intrauterine devices (IUDs) represent a safe, effective, and reversible form of birth control, results of a new study indicate many U.S. women choose sterilization immediately postpartum.1

The current study looked at data from 2001-2008 Nationwide Inpatient Sample, the largest all-payer inpatient care database in the United States, to identify women who had tubal sterilization or IUD insertion performed shortly after giving birth. Researchers found that women had an IUD inserted in one in every 37,000 post-deliveries, while tubal sterilizations were performed one in every 13 postpartum circumstances.1

Like IUDs, tubal sterilization is highly effective and can be initiated in the postpartum period prior to hospital discharge, notes lead study author Maura Whiteman, PhD, an epidemiologist in the Women's Health and Fertility Branch in the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC). However, IUDs have some potential advantages in that they are easily reversible and IUD insertion does not involve a surgical procedure, she explains.

"We undertook this study to see how often IUD insertion was being performed during delivery hospitalizations in the U.S. compared to tubal sterilization," says Whiteman. "We also wanted to examine characteristics associated with the likelihood of undergoing these procedures to assess whether IUDs may be underutilized in some groups relative to tubal sterilization, such as those who may be more likely to experience post-sterilization regret."

Providing effective contraception in the postpartum is an important goal in pregnancy prevention. In 2001, 49% of all pregnancies were unintended, and 21% of those women gave birth within 24 months of a previous birth, according to the CDC.2 Postpartum contraception improves health by lengthening birth intervals: On a global scale, if births are scaled 3-5 years apart, the mother is 2.5 times more likely to survive childbirth, the baby is 1.5 times more likely to survive the first week of life, and 2.5 times more likely to survive to five years of age.3

A recent update to the U.S. Medical Eligibility Criteria for Contraceptive Use reinforces the safe use of intrauterine contraception in the postpartum.

The levonorgestrel-releasing IUD (Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ) and the copper-bearing IUD (ParaGard, Teva Women's Health, North Wales, PA), can be inserted postpartum, including immediately after delivery. The Mirena is listed as Category 2 (benefits theoretically outweigh risks) for insertion less than 10 minutes following delivery of placenta, as well as 10 minutes after placenta delivery up to less than four weeks. The ParaGard is listed as Category 1 (no restrictions on use) for insertion less than 10 minutes after placenta delivery and Category 2 for 10 minutes after placenta delivery to less than four weeks.4

Although IUD expulsion rates are somewhat higher when insertion occurs within 28 days of delivery, continuation rates at six months are similar among women who receive an IUD postpartum and those who plan for delayed insertion, the guidance notes.5,6 A 2009 review of evidence indicates that there is no increase in risk of complications among women who had an IUD inserted during the postpartum period.5 The review notes some increase in expulsion rates occur with delayed postpartum insertion when compared to immediate insertion, and with immediate insertion when compared to interval insertion.5

Regret is real

While many new moms may gravitate to sterilization as a birth control option following hospital delivery, clinicians should pay close attention to age of the mother when explaining contraceptive choices.

In a 2006 review of available data, analysts report that the younger women are at the time of sterilization, the more likely they are to report regretting that decision.7 Women undergoing sterilization at the age 30 years or younger were about twice as likely as those over 30 to express regret, and they were from 3.5 to 18 times as likely to request information about reversing the procedure, researchers note.7

While sterilization regret among younger women has been well-documented, procedures continue to be performed in this age range. In the current study of postpartum procedures, 15% of tubal sterilizations occurred among women who were 24 years old or less.1

What can you do?

What can clinicians do to expand contraceptive options for new mothers? Bring up the IUD as a safe, effective option, says Barbara Clark, MPAS, PA-C, DFAAPA, a clinician at Knox OB/GYN Ltd., a private obstetric/gynecology practice in Galesburg, IL. Clark, who terms herself as a "huge fan of IUDs," says intrauterine contraception is the number one recommended postpartum option in her practice.

"My comment to any patient, including postpartum, is that intrauterine contraception is as effective as sterilization, but it is not permanent, and it is not surgery," says Clark. "I also tell patients that it is one of the most cost-effective options as well, if used for two years or more." 

Most young pregnant women are unsure about the IUD's characteristics. When asked to rank how safe/effective IUDs are compared to pills, injections, or tubal sterilization, 71% were unsure of the device's safety, while 58% were unsure of its efficacy.8

In summary, IUDs are significantly underutilized for contraception in the United States, notes Clark, a participant in the Association of Reproductive Health's (ARHP's) "A Clinical Update on Intrauterine Contraception." (Get slide sets and patient handouts from the ARHP web site, www.arhp.org. Click on "Professional Education," then "View More." Select "A Clinical Update on Intrauterine Contraception.")

"Most patients are very interested when this option is discussed with them, and I frequently have patients ask for an IUD because a friend has recommended it," says Clark. "I think the largest barrier to use is cost, if there is no third-party coverage." Total costs for the Copper T 380A IUD are $647, with total costs for the levonorgestrel IUD at $930; total cost for tubal ligation is $2,978.9

References

  1. Whiteman MK, Cox S, Tepper NK, et al. Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States. Am J Obstet Gynecol 2011; Doi: 10.1016/j.ajog.2011.08.004.
  2. Chandra A, Martinez GM, Mosher WD, et al. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 2005; 23:1-160.
  3. Dolan M. Births, babies and beyond: contraceptive management for postpartum and lactation. Presented at the 2009 Contraceptive Technology Quest for Excellence conference. Atlanta; October 2009.
  4. Tepper NK, Curtis KM, Jamieson DJ, et al. Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR 2011; 60:878-883.
  5. Kapp N, Curtis KM. Intrauterine device insertion during the postpartum period: a systematic review. Contraception 2009; 80:327-336.
  6. Chen BA, Reeves MF, Hayes JL, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010; 116:1,079-1,087.
  7. Curtis KM, Mohllajee AP, Peterson HB. Regret following female sterilization at a young age: a systematic review. Contraception 2006; 73:205-210.
  8. Stanwood NL, Bradley KA. Young pregnant women's knowledge of modern intrauterine devices. Obstet Gynecol 2006; 108:1.417-1,422.
  9. Trussell J, Lalla AM, Doan QV, et al. Cost effectiveness
  10. of contraceptives in the United States. Contraception 2009; 79:5-14.