EXECUTIVE SUMMARY
The American College of Obstetricians and Gynecologists has issued a new committee opinion on the use of long-acting reversible contraception (LARC) in the postpartum period to help stem pregnancies.
- Unplanned pregnancies can happen in the postpartum period. Data indicate 40-57% of women report having unprotected intercourse before the routine six-week postpartum visit.
- Providers are encouraged to begin discussions about postpartum contraception prior to delivery to ensure women have the time and information they need to select the best method for them. Use of LARC methods in the postpartum period is safe and effective.
Unplanned pregnancies can happen in the postpartum period. Data indicate 40-57% of women report having unprotected intercourse before the routine six-week postpartum visit.1,2 The American College of Obstetricians and Gynecologists (ACOG) has just issued a new committee opinion on the use of long-acting reversible contraception (LARC) in the postpartum period to help stem such pregnancies.3
With effectiveness greater than 99%, the IUD and the contraceptive implant represent the most effective forms of reversible contraception and have the highest continuation rates among reversible methods.4 The Contraceptive CHOICE offers definitive proof. This study offered more than 9,000 women counseling on all contraceptive methods and provided contraceptives free of charge; 75% chose LARC methods. At the 12-month follow-up, 86% of LARC users still were using the method, compared with 55% of those who initiated short-acting methods, such as oral contraceptives or depot medroxyprogesterone acetate. In this study, women who used LARC had the highest satisfaction rates and lowest rates of unintended pregnancy.5
Use of LARC in the postpartum period is safe. The US Medical Eligibility Criteria for Contraceptive Use 2016 classifies immediate postpartum initiation of IUDs and implants as Category 1 (no restriction for use) or Category 2 (advantages generally outweigh theoretical or proven risks).6
Many Miss Appointment
While many women may plan to resume or implement a contraceptive method at their postpartum follow-up visit, data indicate up to 40% of women do not attend a follow-up appointment and, as a result, never obtain a birth control method.7 Women who do come in for care may face barriers to receiving a LARC method at that appointment. Some clinics or clinicians may not offer the IUD or implant, or protocols may call for a repeat visit for placement.
ACOG’s committee on obstetric practice, which developed the opinion, encourages providers to begin discussions about postpartum contraception before delivery to ensure women have the time and information they need to select the best method for them, says Ann Borders, MD, MSc, MPH, adjunct assistant professor in the Department of Medical Social Sciences at the Northwestern University Feinberg School of Medicine in Chicago. Borders was co-author of the opinion.
In a statement accompanying the opinion publication, Borders noted, “The period following delivery is a busy, exhausting and often stressful time and immediate postpartum insertion of LARC may eliminate some of the stressors during that time, like scheduling multiple appointments for LARC insertion.”
While expulsion rates for immediate postpartum placement of IUDs are higher, many women find that the advantages of insertion before leaving the hospital outweigh the disadvantages, said Borders. The contraceptive implant does not have contraindications or risks specific to insertion in the immediate postpartum period.
“As obstetricians, we should be prepared to counsel all of our pregnant patients about the option of immediate postpartum LARC,” stated Borders. “We should also support our institutions in developing the infrastructure and processes needed to operationalize this practice.”
Plan for “4th Trimester”
ACOG also has issued an additional committee opinion on optimizing postpartum care.8 The publication is designed to help develop patient-centered, maternal postpartum care in an effort to improve outcomes for women, infants, and families.
In the weeks after birth, women are adapting to multiple physical, social, and psychological changes, such as recovering from childbirth, adjusting to changing hormones, and learning to feed and care for newborns. This “fourth trimester” can present major challenges such as lack of sleep, pain, depression, lack of sexual desire, and urinary incontinence.
“We encourage providers to partner with women during pregnancy to begin planning for the ‘fourth trimester’,” says Alison Stuebe, MD, lead author of the committee opinion and assistant professor in the division of maternal-fetal medicine in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill School of Medicine. “Each woman has different postpartum needs, and we recommend that she and her provider identify members of her postpartum care team and develop an individualized postpartum care plan.”
For all women, the committee opinion calls for a comprehensive postpartum visit that should take place within the first six weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being. It provides an opportunity for the woman to ask questions about her birth experience and the implications of any complications for her future health. It also allows providers to discuss reproductive life plans to ensure each woman can receive her desired form of contraception, if placement of LARC was not done earlier.
REFERENCES
- 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.
- 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.
- Committee Opinion No. 670: Immediate postpartum long-acting reversible contraception. Obstet Gynecol 2016; 128(2):e32-37.
- Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. 20th rev. ed. New York: Ardent Media; 2011.
- Peipert JF, Madden T, Allsworth JE, et al. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012; 120:1291-1297.
- CDC. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-86.
- Gurtcheff SE, Turok DK, Stoddard G, et al. Lactogenesis after early postpartum use of the contraceptive implant: A randomized controlled trial. Obstet Gynecol 2011; 117:1114-1121.
- Committee Opinion No. 666: Optimizing postpartum care. Obstet Gynecol 2016; 127(6):e187-192.
