Your next patient is a young mother of two, and her youngest child is less than a year old. While she was using combined oral contraceptives (COCs) to prevent pregnancy, her busy schedule compromised compliance. The lab results are in: The pregnancy test is positive.

Such a scenario is a familiar one for family planning providers: 35% of pregnancies in the United States are conceived within 18 months of a previous birth.¹ Postpartum contraceptive provision is an important step in preventing short interpregnancy intervals and the associated risks of preterm birth, low birth weight, and preeclampsia.¹ Reducing the proportion of pregnancies conceived within 18 months of a previous birth is one of the objectives of the Department of Health and Human Services’ Healthy People 2020, the national 10-year plan for health promotion and disease prevention. (Contraceptive Technology Update reported on the charge to shorten intervals. See “Interpregnancy interval — You can help women,” March 2014.)

The immediate postpartum period prior to hospital discharge can be an opportune time to offer contraception, because women might be more motivated to use contraception after giving birth and are known not to be pregnant. By inserting long-acting reversible contraceptive (LARC) methods, such as intrauterine devices (IUDs) and the contraceptive implant, immediately postpartum, providers are able to offer access to these methods for women who might not have insurance coverage after delivery or who might not attend their scheduled postpartum follow-up visit.

“Birth spacing, or taking sufficient time in between pregnancies, is vitally important for the health of both women and their babies, and LARC methods are the most effective forms of reversible contraception with the highest satisfaction rates,” says Katharine O’Connell White, MD, MPH, director of the Fellowship in Family Planning program at Boston University/Boston Medical Center. “Offering women such birth control, while they’re still in the hospital, is both incredibly patient-centered — she no longer has to worry about getting pregnant too soon — and cost-effective.”

CONSIDER THE ADVANTAGES

Results of a new study indicate that placement of implants and IUDs immediately postpartum can lead to high satisfaction with the methods.²

To perform the study, researchers enrolled 133 women in a prospective cohort study following immediate postpartum insertion of an implant or IUD at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, both in Baltimore, during eight months of 2011. Women in the study completed an enrollment survey during hospital admission and a follow-up telephone survey at six months and one year postpartum.

At six months postpartum, 72% of women provided follow-up information. Implant users were more likely to be using the originally placed device (40/41, 98% versus 45/55, 82%, P=0.02). Nine women reported IUD expulsions. Five of the nine women underwent IUD replacement following expulsion. When accounting for replacement of expelled IUDs, IUD continuation at six months was 89%, yielding similar continuation rates between groups (P=0.12). At one year postpartum, 51% provided follow-up information. Of those women, 82% still had a LARC method in place, with similar continuation by device type (84% for implants, 81% for IUDs, P=0.96). Among the women reached, no pregnancies were reported. Overall, satisfaction was similarly high in both groups, researchers note.²

For those who might not return for follow-up, the benefits of placing a LARC immediately postpartum greatly outweigh the risks of device expulsion or early removal, the researchers note. Immediate postpartum implant insertion might have the highest rate of continuation (up to three years) in the population who are most vulnerable to rapid repeat and unintended pregnancy, they state.³

There are several barriers to provision of LARC methods in the immediate postpartum setting, including lack of provider training, difficulty with stocking issues within the hospital setting, and challenges with obtaining a reimbursement, states the Intrauterine Devices and Implants: A Guide to Reimbursement website (http://bit.ly/1MhrmeA).

The website is a joint project of the Bixby Center and the American College of Obstetricians and Gynecologists National Family Planning and Reproductive Health Association, National Health Law Program, and the National Women’s Law Center. (To read more about the guide and website, see “Counseling on LARC methods cuts unintended pregnancy rates,” Contraceptive Technology Update, September 2015.) Payment for delivery is often made using a “global fee” that does not specifically reimburse hospitals for the cost of LARC methods or the insertion procedure on a fee-for-service basis, the guide notes.

The ACOG LARC Program website (http://bit.ly/1N82hxZ) confirmed the following states and district have published final or proposed guidance regarding Medicaid reimbursement for postpartum LARC: Alabama, California, Colorado, District of Columbia, Georgia, Illinois, Indiana, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Ohio, Oklahoma, South Carolina, and Washington. (The list is updated on a regular basis. Check it at http://bit.ly/1tlMUPw.)

To help identify opportunities, challenges, and technical assistance needs to improve states’ ability to promote LARCs during the immediate postpartum timeframe, the Association of State and Territorial Health Officials, which is based in Arlington, VA, has established a multistate LARC learning community. With support from the Centers for Disease Control and Prevention and partnerships with the Centers for Medicare and Medicaid Services and the Office of Population Affairs, the organization convened the learning community in August 2014 to help select six states (Colorado, Georgia, Iowa, Massachusetts, New Mexico, and South Carolina) that are establishing Medicaid payment policies or pilot programs to implement immediate postpartum LARC initiatives. Evaluation of the implementation of immediate postpartum LARC in the Learning Community states will be done by researchers at the University of Illinois at Chicago. (You can obtain more information about the Learning Community at http://bit.ly/1SiJMi8.)

GET UP TO SPEED

The U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) classifies immediate postpartum copper IUD insertion as Category 1 and immediate postpartum levonorgestrel intrauterine system insertion in nonbreastfeeding and breastfeeding women as Category 2.

Insertion of the implant is safe at any time in nonbreastfeeding women after childbirth (Category 1 rating). The US MEC classifies the placement of an implant in breastfeeding women less than four weeks after childbirth as Category 2 because of theoretic concerns regarding milk production and infant growth and development. Implants may be offered to women who are breastfeeding and more than four weeks after childbirth because the US MEC classifies delayed insertion as Category 1.⁴

The American College of Obstetricians and Gynecologists (ACOG) recently strengthened its recommendation regarding use of LARC methods as the most effective and safe forms of reversible contraception, with information included on immediate postpartum use.⁵

David Soper, MD, chair of the College’s Gynecologic Practice Committee, says, “ACOG has long recommended LARC as the most effective reversible contraceptive option for most women, including those who have not given birth and adolescents who are sexually active. We continually see more and more data to support and strengthen our recommendations at the same time that more LARC options are becoming available.”

REFERENCES

1. Gemmill A, Lindberg LD. Short interpregnancy intervals in the United States. Obstet Gynecol 2013; 122(1):64-71.
2. Woo I, Seifert S, Hendricks D, et al. Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices. Contraception 2015; 92(6):532-535.
3. Wilson S, Tennant C, Sammel MD, et al. Immediate postpartum etonogestrel implant: A contraception option with longterm continuation. Contraception 2014; 90(3):259-264.
4. Centers for Disease Control and Prevention (CDC). 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. Morb Mortal Wkly Rep 2011; 60(26):878-883.
5. Committee on Gynecologic Practice Long-Acting Reversible Contraception Working Group. Committee Opinion No. 642: Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2015; 126(4):e44-48.