EXECUTIVE SUMMARY

Research indicates that while the number of women receiving immediate postpartum intrauterine devices and implants has increased dramatically in recent years, access to such services is unequal.

  • Although the rate of IUDs or implants after childbirth increased sevenfold over five years (increasing from 1.86 per 10,000 deliveries in 2008 to 13.5 per 10,000 deliveries in 2013), data indicate that about 96% of inpatient postpartum IUDs were placed at urban teaching hospitals.
  • Data suggest that the rate of patients receiving reversible contraception while hospitalized for a delivery still remains less than 2% of the national sterilization rate.

Research indicates that while the number of women receiving immediate postpartum intrauterine devices and implants has increased dramatically in recent years, access to such services is unequal.1

To measure rates of long-acting reversible contraception (LARC), including intrauterine devices (IUDs), contraceptive implants, and tubal sterilization, investigators performed a retrospective cohort study, looking at the 2008-2013 National Inpatient Sample, an all-payer database that’s available publicly. The authors identified delivery hospitalizations with the International Classification of Diseases, 9th Revision, Clinical Modification codes for intrauterine device insertion, contraceptive implant insertion, and tubal sterilization.

Investigators used weighted multivariable logistic regression to examine associations between predictors, such as age, delivery mode, medical comorbidity, payer, hospital type, geographic region, and year, and likelihood of LARC and sterilization to compare characteristics of LARC and sterilization users.

The researchers found that the rate of IUDs or implants after childbirth increased sevenfold over five years, increasing from 1.86 per 10,000 deliveries in 2008 to 13.5 per 10,000 deliveries in 2013.

However, data indicate that about 96% of inpatient postpartum IUDs were placed at urban teaching hospitals, suggesting that the service is not available to women delivering at urban non-teaching and rural hospitals. The analysis also revealed that the rate of patients receiving reversible
contraception while hospitalized for a delivery still remains less than 2% of the national sterilization rate in immediately postpartum women.

Getting an IUD right after childbirth may be more convenient and less painful than insertion at a later office visit for new mothers, according to the paper’s lead author, Michelle Moniz, MD, MSc, assistant professor of obstetrics and gynecology and researcher at the University of Michigan Medical School.

However, the recent analysis indicates that access to this service varies greatly depending on where a woman delivers her baby, she said.

“Maternity clinicians and policymakers should strive to ensure that women have access to the full range of contraceptive options after childbirth and that they are able to make an informed, voluntary, personal choice about whether and when to have another child,” Moniz noted in a statement accompanying the paper’s publication.

Unplanned pregnancies can happen in the postpartum period. Data indicate 40–57% of women report engaging in unprotected intercourse before their routine six-week postpartum visit.2,3 The LARC Program of the American College of Obstetricians and Gynecologists (ACOG) has just established the Postpartum Contraceptive Access Initiative (PCAI) to provide clinical and operational support training for immediate postpartum LARC implementation.

“Immediate postpartum LARC initiation is safe and effective, but is currently uncommon in U.S. hospitals,” says Eve Espey, MD, MPH, professor and chair of the department of obstetrics and gynecology at the University of New Mexico in Albuquerque. “The aim of the Postpartum Contraceptive Access Initiative is to ensure all women have access to the full range of postpartum contraceptive methods before leaving the hospital after a delivery.”

An important aspect of the initiative is to assist providers with the multiple aspects of initiating immediate postpartum LARC insertion, Espey says. First, barriers that prevent access to the full range of contraceptive methods in the postpartum setting must be identified. Those specifically affecting LARC include lack of clinical training opportunities, complex billing and reimbursement requirements, and other administrative hurdles such as stocking and tracking devices, Espey notes.

“Through onsite training and support, ACOG will support implementation of IPP LARC provision at participating hospital sites, allowing women convenient access to the full range of postpartum contraceptive methods with the goal of assisting women in obtaining their desired contraceptive method and birth spacing with higher satisfaction and continuation rates with their choice of postpartum contraception,” Espey says.

Evidence-based research supports the use of a tiered, stage-based approach for implementing immediate postpartum LARC. Current best practices have been incorporated into the initiative’s three-pronged implementation model to support successful immediate postpartum LARC provision at participating hospitals. These phases include capacity building for implementation, onsite hands-on clinical simulation and operational support trainings, and ongoing support through a web-based resource hub and follow-up consultations with immediate postpartum LARC implementation experts.

The creators of the initiative are developing a website that will contain details about the initiative, information about immediate postpartum LARC, and an application to become a participating hospital site. Questions about PCAI can be directed to pcai@acog.org.

Advocacy continues growing for immediate postpartum LARC. The CDC established the 6/18 Initiative, a partnership between providers, payers, and purchasers that treats insurance coverage of immediate postpartum LARC as a way to affect health and costs positively. The creators of the initiative are working to ensure private and public payers reimburse for immediate postpartum LARC insertion by separating payment for LARC from other postpartum services. (For more information on this issue, please visit: http://bit.ly/2reIWJ2.)

REFERENCES

  1. Moniz MH, Chang T, Heisler M, et al. Inpatient postpartum long-acting reversible contraception and sterilization in the United States, 2008-2013. Obstet Gynecol 2017;129:1078-1085.
  2. Brito MB, Ferriani RA, Quintana SM, et al. Safety of the etonogestrel-releasing implant during the immediate postpartum period: A pilot study. Contraception 2009;80:519-526.
  3. Connolly A, Thorp J, Pahel L. Effects of pregnancy and childbirth on postpartum sexual function: A longitudinal prospective study. Int Urogynecol J Pelvic Floor Dysfunct 2005;16:263-267.