By Rebecca H. Allen, MD, MPH

Assistant Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI

Dr. Allen reports she is a Nexplanon trainer for Merck, a Liletta trainer for Actavis, and on the advisory board for Bayer, Actavis, and Vermillion.

It is no secret that long-acting reversible contraception (LARC), such as intrauterine devices (IUDs) and implants, are among the most effective methods. LARC offers other advantages including:1

  • Effectiveness independent from coitus, user motivation, and adherence
  • Highest continuation rates and user satisfaction of all reversible methods
  • No requirement for frequent visits for resupply
  • No requirement for additional funding for consistent use once placed
  • Rapid return to fertility after removal
  • Few contraindications

If we are ever to reduce the unintended pregnancy rate in the United States and the rate of rapid repeat pregnancies after birth, then LARC methods should be made more accessible to women. One option for timing of placement of intrauterine devices is within 10 minutes of the delivery of the placenta, the so-called “postplacental” insertion. Another option is within the first 48 hours postpartum, which is called “immediate postpartum” insertion. What is the evidence behind this practice and how can it be incorporated into your hospital?

Immediate postplacental IUD insertion occurs ideally within 10 minutes of the delivery of the placenta. There is no magic to the 10-minute interval, however, and likely any time in the delivery room is acceptable. The United States Medical Eligibility Criteria for Contraceptive Use allows for insertion of IUDs immediately postpartum except in cases of puerperal sepsis (and chorioamnionitis) (see Table 1). The advantages to immediate postpartum and postplacental IUD insertion are that the cervix is already open, both the patient and provider are already present, and any side effects the patient experiences due to the IUD may be masked by the normal postpartum lochia.

 

Table 1. Recommendations for IUD Use Postpartum

Postpartum (breastfeeding or non-breastfeeding including postcesarean delivery)


CuT-380A



LNG-IUS

< 10 min after delivery of the placenta

2

1

10 min after delivery of the placenta to < 4 wks

2

2

4 wks

1

1

Puerperal sepsis

4

4

CuT-380A = copper intrauterine device (copper T 380A); LNG-IUS = levonorgestrel intrauterine system

Categories: 1 = a condition for which there is no restriction for the use of the contraceptive method, 2 = a condition for which the advantages of using the method generally outweigh the theoretical or proven risks, 3 = a condition for which the theoretical or proven risks usually outweigh the advantages of using the method, 4 = a condition that represents an unacceptable health risk if the contraceptive method is used.

SOURCE: Centers for Disease Control. U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR 2010;59:1-86.

Immediate postpartum and postplacental IUD insertion has been studied worldwide since the 1980s in countries such as China, Mexico, and Egypt. It is only recently, however, that studies of this practice have been performed in the United States with the resurgence in IUD popularity. One concern that providers have is the risk of expulsion with immediate postpartum and postplacental IUD insertion. The latest Cochrane Review on the subject reports an almost five times higher risk of expulsion with immediate insertion compared to insertion at 4 to 6 weeks’ postpartum (odds ratio [OR], 4.89; 95% confidence interval [CI], 1.47-16.32).2 However, the rate of expulsion will depend on provider experience, type of device, and whether the placement occurs after vaginal delivery or cesarean section. Although experienced providers may report an expulsion rate of 5-10%, those first starting out may see rates as high as 20%. Nevertheless, if expelled devices are recognized and replaced as desired, the rates of IUD use at 6 months with immediate insertion compared to insertion at 4 to 6 weeks are actually higher (OR, 2.04; 95% CI, 1.01-4.09). This is because women may not return for their 4- to 6-week postpartum visit, as multiple studies have shown.1 A decision analysis that used an expulsion rate of 18% for immediate postpartum insertion still concluded that this practice was cost-effective, saving $282,540 per 1000 women over 2 years and preventing 88 unintended pregnancies.3 Besides the higher risk of expulsion, published studies do not show an increased risk of bleeding, infection, or other complications. Early follow-up is advised (2 weeks postpartum) to assess for expulsion and trim IUD strings because they lengthen as the uterus involutes.

Placement at the time of cesarean delivery has a lower expulsion rate compared to after vaginal delivery. Levi et al conducted a randomized, controlled trial of 112 women that compared placement at the time of cesarean delivery to placement at 6 weeks postpartum.4 In this trial, more women were using an IUD at 6 months in the immediate placement arm (40/48, 83%) compared to 6-week placement (32/50, 64%). Furthermore, the expulsion rate in the cesarean group was 8% compared to 2% in the 6-week postpartum placement group. For trans-cesarean insertion of an IUD, the device can be inserted through the hysterotomy with the hand, ring forceps, or the IUD inserter with arms out of the applicator. The strings are then pushed down through the cervix with ring forceps. Levonorgestrel IUD (LNG-IUD) strings, which are longer, need to be trimmed prior to this step. In this study, only 56% of trans-cesarean placed IUD strings were visualized at the 6-week postpartum check, which is not unusual.4 Therefore, becoming handy at removing IUDs without visualized strings in the office with alligator forceps and ultrasound guidance is important.

Placement at the time of vaginal delivery can also be accomplished by ring forceps or the hand. With the non-dominant hand on the fundus, the IUD is placed through the cervix up to fundus and released. Copper IUD strings do not have to be trimmed in advance, but LNG-IUD strings should be trimmed at the level of the cervical os. If using a ring forceps, the LNG-IUD should not be gripped tightly or there is a risk of breaking the hormone reservoir in the stem. It is still under study if there is a higher expulsion rate in the copper IUD compared to the LNG-IUD.

Although placement of the devices is relatively straightforward, the logistics of reimbursement at the time of the postpartum hospitalization are not. Most insurers have not changed their policies to allow for reimbursement of the device outside of the global fee for delivery. In certain states, however, Medicaid is leading the way in changing reimbursement policies for postpartum LARC. Moniz and colleagues recently conducted a telephone survey of Medicaid offices and received responses from 39 states and the District of Columbia.5 They found that 15 agencies were providing separate or increased bundled payment, nine were considering providing payment in the future, and 16 were not planning to provide enhanced payment. For those agencies not providing payment, the major concern was the upfront cost and also setting a precedent of “carve out” payments for inpatient care. There were also some misperceptions about the safety of postpartum LARC. The authors concluded that having local state champions educate and lobby for this change would be most helpful, especially if it aligns with the state Medicaid program’s other goals, such as reducing preterm birth or neonatal abstinence syndrome. There are plenty of published studies documenting the cost-effectiveness of postpartum LARC, as well as websites that can assist with lobbying efforts (http://bit.ly/1WPJCgc).

Even if the state Medicaid program permits postpartum LARC, the next hurdle is implementing a billing process. Even though my own state, Rhode Island, is on the list of states allowing this service, full-scale implementation has been held up by billing uncertainties, and no formal clarification has come from the managed Medicaid plans. Therefore, hospital administrators are hesitant to allow providers to begin inserting the devices. I can only hope this will be resolved so we can offer women this important and valuable service.

REFERENCES

  1. ACOG Committee Opinion No. 642. Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. October 2015. Obstet Gynecol 2015;126:e44-e48.
  2. Lopez LM, et al. Immediate postpartum insertion of intrauterine device for contraception. Cochrane Database Syst Rev 2015;6:CD003036.
  3. Washington CI, et al. Timing of postpartum intrauterine device placement: A cost-effectiveness analysis. Fertil Steril 2015;103:131-137.
  4. Levi EE, et al. Intrauterine device placement during
  5. Moniz MH, et al. Characterization of Medicaid policy for immediate postpartum contraception. Contraception 2015; Sep 28 [Epub ahead of print].