Time to look at LARC use in postpartum teens
Executive Summary
Postpartum placement of long-acting reversible contraception (LARC) might be an effective way to address unplanned pregnancies in adolescents. Efficacy is key in preventing rapid repeat pregnancy; 20% of adolescent mothers give birth again within two years.
• Insertion of an intrauterine device or contraceptive implant immediately postpartum ensures reliable contraception for teens when they are highly motivated to prevent pregnancy and are already in the healthcare system, according to a committee opinion from the American College of Obstetricians and Gynecologists.
• Findings from a new study indicate postpartum LARC use decreases rapid repeat pregnancy among first-time adolescent mothers.
Postpartum placement of long-acting reversible contraception (LARC) might be an effective way to address unplanned pregnancies in adolescents. Efficacy is key in preventing rapid repeat pregnancy; 20% of adolescent mothers give birth again within two years.1
Insertion of an intrauterine device (IUD) or contraceptive implant immediately postpartum ensures reliable contraception for teens when they are highly motivated to prevent pregnancy and are already in the healthcare system, according to a committee opinion from the American College of Obstetricians and Gynecologists.2
The U.S. Medical Eligibility Guidelines for Contraceptive Use ranks use of the Copper T-380A IUD as a "Category 1" (no restrictions) for insertion less than 10 minutes after delivery of the placenta, and levonorgestrel IUDs as a "Category 2" (a condition for which the advantages of using the method generally outweigh the theoretical or proven risks) for the same scenario.3 For insertion after 10 minutes past delivery of placenta to up to four weeks postpartum, both IUDs and the implant are rated as Category 2.3
Findings from a new study indicate postpartum LARC use decreases rapid repeat pregnancy among first-time adolescent mothers.4 To help perform the retrospective cohort study, researchers looked at 340 first-time adolescent mothers age 19 or below at an urban teaching hospital. They examined the rate of repeat pregnancy in two years.
Researchers recorded a repeat pregnancy rate of 35% among the 340 first-time adolescent mothers with documented follow-up time. Logistic regression analysis comparing adolescents with and without repeat pregnancy revealed that leaving the hospital postpartum without initiating any contraception was associated with significant increase risk of repeat pregnancy (odds ratio [OR] = 2.447, 95% confidence interval [CI] 1.326-4.515). Follow up within eight weeks postpartum was associated with lower chance of repeat pregnancy (OR = 0.322, 95% CI 0.172-0.603). Initiation of a LARC method (either an intrauterine device or subdermal implant) by eight weeks postpartum also was associated with decreased chance of rapid repeat pregnancy (OR=0.118, 95% CI 0.035-0.397).
"Adolescent mothers who initiate a LARC method within eight weeks of delivery are less likely to have a repeat pregnancy within two years than those who choose other methods or no method," note researchers. "First-time adolescent mothers should be counseled about this advantage of using LARC."
Use of LARC methods offer the most effective rates against unplanned pregnancy, says Veronica Gomez-Lobo, MD, director of pediatric and adolescent obstetrics and gynecology at MedStar Washington Hospital Center and Children’s National Medical Center, both in Washington, DC. When patients get busy and don’t return for the first postpartum visit at six weeks, immediate postpartum initiation provides protection, notes Gomez-Lobo, a coauthor of the current paper. Women usually ovulate at four weeks if they are not breastfeeding; again, immediate LARC placement provides protection before the first six-week visit, she adds.
Take a look at implant
Offering the contraceptive implant to adolescent mothers immediately postpartum is cost-effective, according to results from a recently released study.5 Previous investigation of adolescents enrolled in a Colorado prenatal-postnatal program indicated that rapid repeat pregnancy was significantly decreased compared with control participants, with excellent continuation of device use one year after delivery.6 However, at the time, implants offered this way were not covered by payers, including Medicaid, says Leo Han, MD, fourth-year resident in the Department of Obstetrics and Gynecology at the University of Colorado School of Medicine in Aurora.
Researchers wanted to perform the cost-effectiveness study not only to demonstrate it would be cost-effective, but to put a dollar/savings figure on offering implants postpartum, explains Han, lead author of the current paper. To conduct the study, 171 participants in the Colorado adolescent prenatal-postnatal program were enrolled in a prospective observational study of implant insertion, with 225 women enrolled in the standard contraceptive initiation arm for comparison. Researchers looked at implant discontinuation, repeat pregnancies and pregnancy outcomes, and compared the anticipated public expenditures for implant recipients and comparisons at six, 12, 24, and 36 months postpartum using actual outcomes of the cohort and Colorado Medicaid reimbursement estimates. Costs were normalized to 1,000 adolescents in each arm and included one year of well-baby care for delivered pregnancies.
At six months, the expenditures of the implant group exceeded the comparison group by $73,000, statistics indicate. However, at 12, 24, and 36 months, researchers found that publicly funded implants would result in a savings of more than $550,000, $2.5 million, and $4.5 million, respectively. For every dollar spent on the implant program, $0.79, $3.54, and $6.50 would be saved at 12, 24, and 36 months. Expenditures between the implant and comparison groups would be equal if the comparison group pregnancy rate was 3.8%, 18.6%, and 30.5% at 12, 24, and 36 months; actual rates were 20.1%, 46.5%, and 83.7%.
Good news: Shortly after the initial presentation of this data, Colorado Medicaid began reimbursing for immediate postpartum implant placements, says Han.
- Schelar E, Franzetta K, Manlove J. Repeat teen childbearing: differences across states and by race and ethnicity. Child Trends Research Brief 2007; accessed at http://bit.ly/1kmyUdb.
- Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 120:983-988.
- Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.
- Damle LF, Gohari AC, McEvoy AK, et al. Early initiation of postpartum contraception: Does it decrease rapid repeat pregnancy in adolescents? J Pediatr Adolesc Gynecol 2014; doi: 10.1016/j.jpag.2014.04.005.
- Han L, Teal SB, Sheeder J, et al. Preventing repeat pregnancy in adolescents: is immediate postpartum insertion of the contraceptive implant cost effective? Am J Obstet Gynecol 2014; doi:10.1016/j.ajog.2014.03.015.
- Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012; doi: 10.1016/j.ajog.2012.04.015.
